Practicum Handbook Summer 2012

Xavier University
Counseling Practicum Handbook

COUN 773
Counseling Practicum

Department of Counseling
3800 Victory Parkway
Cincinnati, Ohio 45207-3226
Phone (513) 745-3655
Fa (513) 745-2!20
Updated Summer 2012
1
Phone (513) 745-3655
Fa (513) 745-2!20
Dear Student,
This handbook is designed to familiarize you with the content, reuired forms, procedures, and
the e!pectations for "#U$ %%&, "ounseling 'racticum( The "ounseling 'racticum course is designed as
a Uni)ersity super)ised e!perience that meets regularly according to the schedules you will see on the
enclosed sample syllabi( *hile you will be e!pected to work with actual clients seeking counseling
assistance, this courses differs from the +00 clock hour internship reuirements in the program( The
basic purpose of practicum is to help students learn foundational and advanced counseling skills under
the primary supervision of Xavier Faculty in cooperation with the site supervisor. The basic purpose of
internship is to help students learn the full range of services and duties at a selected site under the
primary supervision of a site based supervisor.
Required pre,reuisites for enrolling in these courses include, at minimum and with no
e!ceptions, satisfactory completion of the following courses or their eui)alent-
"#U$ .&& "ounseling Theories and Techniues
"#U$ .&+ /roup 'rocess
"#U$ .%0 'sychological 1 2chie)ement Tests
"#U$ +&1 "ounseling 3ssues 1 4thics
"#U$ ++0 "ounseling 're,'racticum
2lso, you will note from the enclosed syllabus, the workload for this course is significant(
Students are strongly encouraged to limit their enrollment in other program courses while in)ol)ed with
"#U$ %%&(
The practicum e!perience is an important process by which students begin to directly apply their
counseling skills( The learning that occurs from such courses is e!cellent preparation for the integrati)e
internship and later practice as a professional counselor( *e wish you well5
Sincerely,
Dr( 6utch 7osey, '"",S, $""
"linical "oordinator
2
Table of Contents
/eneral 8euirements9"ourse :ormats(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( ;
Summer 'racticum Schedules, T6 Testing, 6ackground "hecks((((((((((((((((((((((((((((((((((((((((((p( .
3dentifying "lients 1 7iability 3nsurance((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( +
4thical "onsiderations(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( %
4lectronic 8ecording 'rocedures(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( < 1 &&
Se)en Steps to Start 'racticum =======================((p(0
3nformed "onsent :orm(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( 10
2uthorization for 8elease of 3nformation===================((p( 11
7etter of 3ntroduction to School9"ommunity sources(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( 12
"ounseling State 2ppro)al :orms(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( 1&,1<
'racticum 2ffiliation 2greement(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( 10,20
"ourse #b>ecti)es=======((=====================(p( 21
"ounseling 'racticum 3ntent :orm((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( 22
"ounseling 'racticum Sample Syllabus((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( 2&,&2
Technical "onsiderations for Digital 8ecording((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( &&
/uidelines for *riting 3nitial 3nter)iew 8eport(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( &;
Sample 3nitial "lient 8eports(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( &.,;2
"ounseling 'racticum Super)ision "ontract ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( ;&
'rogress $ote, Self,4)aluation 1 Termination(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( ;+,.1
'erformance 2ssessment ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( .2,+1
'racticum Student Sur)ey Demographic :orm and Student Sur)ey=========(p( +2,+&
3nternship at a /lance===========================(p( ++
School "ounseling Summer 3nternship 'olicy and 2pplication===========p( +%,+<
3nternship 3ntent :orms((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((p( +0,%0
&
General Requirements/Course Formats
PrePracticum

6eginning the 2011 summer semester, the counseling program established the "#U$ ++0 're,
'racticum course( 2ll students will be reuired to participate in the course prior to taking 'racticum
"#U$ %%&( The 're,practicum class is an e!periential, super)ised e!perience in counseling through
practical e!ercises and role,played scenarios that focus on basic counseling skills such as reflecting
feelings, constructing influencing responses and non,)erbal techniues in counseling( Students will be
e!pected to e)aluate their own and peers? learning and impro)ement through self,reflection and peer
critiue e!ercises(
Practicum
The #hio "ounselor, Social *orker and @arriage and :amily Therapist 6oard A#"S*@:T6B,
the Centucky "ounseling 6oard AC"6B, The #hio Department of 4ducation A#D4B, and The "ouncil
for 2ccreditation "ounseling and 8elated 4ducational 'rograms A"2"84'B, all reuire that students
successfully complete super)ised practicum e!periences that total a minimum of 100 clock hours as
follows-
;0 hours of direct ser)ice with clients, including e!perience in indi)idual counseling and group
work( 10 of the 40 hours must be in group counseling (!"#$FT %oard&.
*eekly interaction Awith an a)erage of one hour per week of indi)idual and9or triadic super)ision
which occurs regularly o)er the semesterB with an appropriate faculty or site super)isor(
2n a)erage of one and one half hours per week of small group super)ision that is pro)ided on a
regular schedule o)er the semester by the appropriate Da)ier faculty member(
4)aluation of the student?s performance throughout the practicum including a formal e)aluation after
student completion of the e!perience(
"ounseling 'racticum is structured to pro)ide e!periences in se)eral ma>or areas-
:irst, students will de)elop and enhance indi)idual and group counseling skills )ia direct counseling
with clients(
Second, students will demonstrate their work through the presentation of audio recorded, video
recorded or live observation of sessions with their clients( Such electronic or digital recording of
these sessions permits faculty and peer critiue of the student?s counseling skills and contributes to
the learning of fellow students(
Third, while students will e!perience large group instruction on course topics, they will primarily
encounter direct super)ision )ia participation in a small group with fellow students( 4ach small
group will be super)ised by an appropriately credentialed faculty member(
3t is important to note that the satisfactory de)elopment of counseling skills is but one aspect of
student e)aluation( 2nother is the student?s openness to super)ision and acti)e participation in this
learning e!perience(
;
.
!ummer Practicum !c"e#ules
3n order to meet the time demands and reuirements necessary for "#U$ ++0 're,'racticum and %%&
'racticum courses, both will meet on an e!tended schedule during the summer term(
"tudents in the "chool !ounseling 'rogram are advised that ()1* schedules usually end the first week
of +une, therefore it may be impractical to select a school as a site for a summer practicum. "chool
!ounseling 'rogram students may select an agency based site to complete summer practicum. The goal
is to practice counseling, not to speciali-e in a particular field of work.
Therefore, these classes are held twice a week for 10 weeks from mid,@ay through mid,Euly(
T6 Testing
Some organizations will reuire practicum9intern students to show e)idence of a recent negati)e T6 test(
Students can contact their physician or the Da)ier Fealth and "ounseling "enter to schedule an
appointment for the test(
The Fealth and "ounseling "enter charges G1. and schedules the tests on @ondays, Tuesdays,
*ednesdays, and :ridays between the hours of <-&0 2@ H ;-&0 '@(
"all A.1&B %;., &022 for details(
:inger,'rinting96ackground "hecks
7ikewise, some practicum9internship sites will reuire a background check and finger printing(
8efer to the 2ttorney /eneral?s website at http-9www(ag(state(oh(us9
or contact the 6"313 in 7ondon, #hio at A%;0B <;.,2&%. will all fingerprinting uestions(
"tudents are strongly encouraged to investigate specifically if the T% Test and .or the background checks
are re/uired with the practicum.intern site before scheduling these steps.
+
$#entif%ing Clients
T"e responsibilit% for i#entif%ing appropriate clients rests &it" t"e stu#ent' Xavier students ought
to pace themselves over the course of the semester regarding numbers of clients in a given week. n
average, students will see *)0 clients per week in a community setting and 0)4 clients per week in a
school setting. n average, sessions in a community based setting last 41)10 minutes, while sessions in
a school setting last *1)00 minutes.
School "ounseling students may find clients in a school setting, if permission from the school counselor
is granted( "ommunity counselors may find clients through a community agency( 2gain, prior appro)al
to work with these clients must be granted by the agency(
2dditionally, students may begin to work with clients at the sites where they hope to later ser)e their
internships( Such an arrangement allows for a more in,depth e!perience for the student and can better
enhance the relationship with the future internship site9super)isor(
Students may wish to use the enclosed letter of introduction to present to potential sites for client access
Asee p( 0B(
Students should not begin counseling with clients prior to the beginning of the 'racticum course(
(o&e)er* it is "ig"l% a#)isable t"at suitable clients be i#entifie# in a#)ance so t"at stu#ents can
meet t"e assigne# #ea#lines #uring t"e semester'
+iabilit% $nsurance
Students are co)ered with liability insurance through the Uni)ersity by paying a mandatory fee when
they register for "ounseling 'racticum( "o)erage amounts are G2,000,0009G;,000,000( Some sites will
reuest proof of this insurance( 'lease contact Dr( 7osey to obtain a "ertificate of 7iability 3nsurance
form(
Students are encouraged to also carry their own professional liability insurance( The 2merican
"ounseling 2ssociation offers an affordable rate for this insurance for student members( "ontact 2"2
@embership Ser)ices at 1,<00,&;%,++;% ! 222 or at www(counseling(org for information(
%
,t"ical Consi#erations
!tu#ents are strongl% remin#e# of t"e necessit% of strict a#"erence to et"ical be"a)iors
&"ile in)ol)e# in t"e practicum courses' *hile students ha)e been thoroughly e!posed to ethical9legal
considerations in the pre,reuisite course, "ounseling 3ssues and 4thics, se)eral key points are repeated
here-
Do no harm(
2)oid dual relationships in all counseling acti)ities(
:ull and complete disclosure about the counseling process for these courses must be pro)ided to the
client Asee the reuired disclosure9consent form on the following pageB(
"onfidentiality must be appropriately maintained at all times( This includes the professional care of
records, whether written or electronic( "lients must be made aware of the circumstances under which
confidentiality may be broken prior to the beginning of the counseling session( 'lease also be sure to
let the client know that confidentiality is limited in this e!perience in that your professor and fellow
super)ision group members may hear or )iew the electronically recorded sessions for instructional
purposes(
Signed parent9guardian consent must also be obtained whene)er clients are under the age the age of
eighteen(
3n any instance where a student is concerned about the welfare of a client or feels an ethical9legal
issue is in uestion, the student is to immediately contact the Da)ier faculty member for consultation(

<
,lectronic Recor#ing Proce#ures
2s mentioned earlier, audio or )ideo recording with clients must occur at all times with full disclosure to
the client prior to recording your inter)iews(
See page 2. for some important considerations for your audio,recording for "ounseling 'racticum(
The recorded sessions for "ounseling 'racticum may be conducted off site or in Failstones Fall( SignH
up sheets for 'racticum room reser)ations can be found on the doors to the practicum rooms in
Failstones(
'lease take care to follow all instructions for )ideo recording that will be gi)en to you during the
beginning of class(
The "ounseling 'rogram has + )ideo cameras a)ailable for students to use at school or at practicum
sites( 3f you are interested in reser)ing one, contact Diane St( "lair at StclairdI!a)ier(edu(
Please be sure to secure all t"e equipment &"en %ou finis" recor#ing-
0
7 !teps to !tart Practicum &it" .a)ier Uni)ersit%
1( "omplete the 'racticum 3ntent :orm at least &0 days prior to starting practicum
and submit to the "linical "oordinator, Dr( 6utch 7osey(
2( The semester prior to starting practicum, select a practicum site and site super)isor(
a( @ental Fealth "ounseling 'racticum Site- 2n agency, hospital or entity where
a student can practice basic assessment skills, indi)idual counseling, and group
counseling under super)ision(
b( School "ounseling 'racticum Site- 2 school where a student can practice
indi)idual counseling, group counseling, and classroom guidance(
c( Site Super)isor- Folds a minimum of a @aster?s degree in counseling or
related profession with eui)alent ualifications, including appropriate
certifications and9or licenses( Fas a minimum of two years e!perience school
or mental health counseling and has rele)ant training in super)ision( Jualified
site super)isors include, but are not limited to School "ounselor, 'rofessional
"linical "ounselor, 'rofessional "ounselor, 3ndependent Social *orker,
@aster le)el Social *orker, 'sychologist, School 'sychologist, 'sychiatrist,
'sychiatric $urse, 3ndependent "hemical Dependency "ounselor, "ertified
'astoral "ounselor or 7icensed 8ehabilitation "ounselor( 2s an e!ample, an
unlicensed minister would not ualify as a site super)isor(
&( 'ro)ide your site super)isor with an 2ffiliation 2greement, @id,term e)aluation,
:inal e)aluation, Da)ier 3nformed "onsent :orm, 2uthorization for 8elease of
3nformation :orm and your semester schedule(
;( 8euest signature from your site super)isor Aor his or her administratorB on the
2ffiliation 2greement and return 2ffiliation 2greement to Dr( 7osey preferably
before the first class session but no later than the second class meeting for
'racticum(
.( 'lan your semester to be present at all class sessions( 3f a student is planning an
e!tended )acationK anticipates e!tended family lea)e or has other obligations
during a practicum, she or he may need to postpone practicum until her or his
a)ailability stabilizes(
+( Upon meeting your Da)ier super)isor, sign and date a Da)ier super)isory
agreement by the third class meeting(
%( $otify your 'racticum 3nstructor of any changes or issues with your practicum
site immediately( 3f you intend to change super)isors after starting your
practicum e!perience, you will need to notify Dr( 7osey and ha)e prior
appro)al(
10

Gra#uate Counseling Programs
/0132 7303400
Dear "lient,
The following statement ensures your right to be informed of the credentials of your counselor, the
super)isory relationship and the purpose of recording(
is a /raduate "ounseling Student under the super)ision of 3nstructors in the
Department of "ounseling at Da)ier Uni)ersity( The /raduate "ounseling Student has recei)ed pre)ious
training in counseling and is authorized to counsel under the super)ision of a Da)ier Uni)ersity "ounseling
'rogram instructor( The /raduate "ounseling Student can be reached at the following number in the e)ent
of an emergency ( 3f you are currently recei)ing ser)ices from a psychiatrist,
psychologist, counselor or social worker, please inform the /raduate "ounseling Student so that she9he may
obtain permission to meet with you at this time(
The purpose of super)ision by Da)ier "ounseling 'rogram 3nstructors is to achie)e the best clinical care for
clients( Da)ier "ounseling 'rogram 3nstructors are reuired to super)ise /raduate "ounseling Students as
part of their continuing education reuirement in the field of counseling( Though all information
communicated by you during your counseling is confidential, the /raduate "ounseling Student is reuired
by #hio law to inform the Da)ier instructor of the progress of counseling, which may include progress notes
and test results( 7aws concerning confidentiality apply to Da)ier faculty as well as the /raduate "ounseling
Student( $o one other than the /raduate "ounseling Student and his9her super)isory group may ha)e access
to this information without your written consent, with the following e!ceptions- 1B where we determine that
the client may be dangerous to self or othersK 2B as otherwise reuired by law Ae(g(, court order, report of
child or elder abuseB(
The counseling sessions will be audiotaped9)ideotaped and said audio or )ideo tapes may be used only for
instructional purposes in order to enhance the ser)ices being pro)ided to clients of the /raduate "ounseling
'rogram at Da)ier Uni)ersity( Lour signature signifies awareness of the electronic recording of the sessions
and your permission to use these recordings for teaching purposes at Da)ier( Lour signature further signifies
your awareness of the fact that if your audio tape or )ideo tape is shown to your /raduate Student
"ounselor?s super)isory group, confidentiality may not be assured( Lour permission e!tends through the
20 semester(
Sincerely,
/raduate "ounseling 'rograms
Da)ier Uni)ersity

2raduate !ounseling "tudent
3 ha)e read and understand the contents of this letter(

!lient "ignature . 3ate 'arent.2uardian if $inor . 3ate
11
3nformed "onsent :orm
Phone (513) 745-3655
Fa (513) 745-2!20
5UT(OR$65T$ON FOR T(, R,+,5!, OF $NFOR75T$ON
Name8 DO98 !!:8

3, , hereby authorize the Da)ier Uni)ersity /raduate
"ounseling 'rogram to release to, obtain from, e!change with
including but not limited to information concerning drug and9or alcohol abuse related conditions, and or
psychiatric9psychological conditions(
Specific information to be release, obtained or e!changed-
@edical 8ecords 4)aluation 8eports Treatment 8ecords
Summary of "ontacts Diagnosis 1 'rognosis 8ecommendations
Social9:amily Fistory #ther AspecifyB
The purpose or need for this disclosure or e!change of information is-

3 understand that 3 may re)oke this authorization at any time in writing to the Super)isor of 8ecord for the
/raduate "ourse in the 2gency and School "ounseling 'rogram at Da)ier Uni)ersity( 3 understand this
authorization will automatically e!pire 00 days after the date of authorization if 3 do nothing(

Signature of "lient9'arent9/uardian

Date

Signature of "lient, if @inor

Date

*itness9"ounselor Trainee

Date
12
Note to Part% Recei)ing t"e $nformation8 This information is being disclosed to you from records whose
confidentiality may be protected by :ederal 7aw( 8e,disclosure is prohibited without written consent of the
person to whom it pertains(
1&
Phone (513) 745-3655
Fa (513) 745-2!20
Dear "olleague,
2s you will remember from your graduate school days, indi)iduals completing their @aster?s Degree
'rogram in "ounseling must successfully complete a counseling practicum e!perience and, later, a
comprehensi)e internship(
The graduate student who has approached you for assistance is reuired to complete a total of 100 clock
hours in "ounseling practicum acti)ities( #f these 100 clock hours, ;0 hours must be in direct
counseling ser)ices with clients(
3t would be most helpful if you would consider referring appropriate clients to work in a counseling
relationship with our student( *hile you would pro)ide the necessary administrati)e super)ision to
facilitate this arrangement, the Da)ier :aculty teaching these courses Aall duly licensed by the #hio
"ounselor and Social *orker 6oard and9or the #hio Department of 4ducationB will pro)ide clinical
super)ision of the counselor in training(
7ikewise, the Uni)ersity pro)ides liability insurance for the student for these counseling acti)ities(
*e certainly appreciate any assistance you may pro)ide in this effort( 'lease do not hesitate to call me
with any uestions or concerns you may ha)e(
Sincerely,
Dr( 6utch 7osey
.1&,%;.,10&%
loseyrI!a)ier(edu
1;
!tate 5ppro)al Forms
A"linical @ental Fealth "ounseling Students #nlyB
Some practicum students enrolled in "linical @ental Fealth "ounseling working in #hio may need to
complete the ;Professional Counselor Training !uper)ision 5greement< found on pages 1&,1+( The
#"S*@:T board prefers on,line registration a)ailable at http-99www(cswmft(ohio(go)(
Lou will need to complete this form for "ounseling 'racticum only if reuested to do so by an off,
site super)isor(
:or e!ample- Lou are completing a practicum Anot internshipB at an off,site setting such as "atholic
Social Ser)ices( 3n order for the off,site super)isor to bill for ser)ices, you must be granted
M"ounselor TraineeN status by the #hio 6oard( "T status can be obtained by sending a completed
'rofessional "ounselor Training Super)ision 2greement form to the 6oard Asee pages 1&,1.B or
registering on,line( Up to date forms are a)ailable on the #"S*@:T website(
3n the abo)e e!ample, the super)isor must be a 'rofessional "linical "ounselor with Super)ision
endorsement( Da)ier Uni)ersity super)isors will not hold liability for billable ser)ices off site(
'lease note that you must include proof of registration in the 'racticum and attach it to this form
when you send it to the 6oard( Lou can accomplish this by printing out your Da)ier unofficial
transcript that shows the course registration Asee e!ample, p( 1+B(
Juestions regarding the need to complete this form should be directed toward your practicum
instructor or Dr( 7osey(
1.
!t
at e
of
O"io
Counselor* !ocial =or>er an# 7arriage ? Famil% T"erapist 9oar#
0@ =est 9roa# !treet* !uite 1@70
Columbus* O"io 33A100B1B
Tel8 /4132 344@B1A FaC8 /4132 7AD77B@
PROF,!!$ON5+ COUN!,+OR
TR5$N$NG !UP,RE$!$ON 5GR,,7,NT
$nstructions to applicant8
1( @ake additional copies of this form in the e)ent you ha)e more than one super)isor during the super)ised
practice time reuired for licensure(
2( This form must be filed at the beginning of the training e!perience(
&( 3ndi)iduals who are registering e!perience with the #hio "ounselor and Social *orker 6oard must ha)e a
master?s degree or 'h(D( in Counseling( 6e certain your program meets this reuirement as specified in board
rule ;%.%,1&,0&( Degrees in psychology, social work and marriage and family therapy are not considered
degrees in counseling(
;( 3ndi)iduals must register practica and internships( 3ndi)iduals with a master?s degree in counseling must ha)e
a total of two years A&000 hoursB which must be post '" A'rofessional "ounselorB( 3ndi)iduals with a
Doctorate must ha)e two years of e!perience, one year A1.00 hoursB in an appro)ed doctoral internship and
one year A1.00 hoursB which must be competed after the degree is conferred(
.( During the training period, you must refer to yourself as a Counselor Trainee or Professional
Counselor/Clinical Resi#ent' Lou must hold a )alid 'rofessional "ounselor 7icense in order to use the
'"9"linical 8esident title(
+( Lou must ha)e one hour face,to,face super)ision for each 20 hours of work(
%( 2ll super)ised e!perience for licensure must be documented as specified in board rule ;%.%,1%,01
D' Please attac" proof of enrollment in a practicum or interns"ip for appro)al'
7'" '" '""
P5RT 58 To be complete# b% super)isee SSO , ,
1( $ame of 2pplicant Daytime 'hone
:irst @iddle 7ast
2( 2ddress
$umber Street "ity State Pip
&( $ame of Super)isor 7on S( Criner Title 'h(D(
;( 2ddress of Super)isor Da)ier Uni)ersity 'hone .1&(%;.(&+..
.( $ame, address and scope of practice of setting in which super)ision is taking place-
"ounselor 4ducation 1 Training
Da)ier Uni)ersity
"incinnati, #F ;.20%,&22+
1+
S 2 @ ' 7 4
+( Lour super)isor?s areaAsB of competence in counseling Aplease attach professional disclosure statement of
super)isorB-
"ounselor 4ducation 1 Super)ision
3ndi)idual 1 /roup "ounseling, "areer "ounseling
%( Describe the duties you plan to perform( /For Clinical Resi#ents Per rule 370713@3 /a2 a minimum of 0@
percent of t"e &or> consists of facetoface client contact in)ol)ing t"e #eli)er% of clinical counseling
ser)ices* &"ic" inclu#es t"e #iagnosis an# treatment of mental an# emotional #isor#ers2'
3ndi)idual "ounseling
8eport writing
<( Dates of super)ision at this setting- :rom DD9DD to DD9DD
mo/%r mo/%r
Please suppl% estimate# en#ing #ate' =e no longer appro)e ongoing status'
Total number of hours of super)ised e!perience- +0
Total *ork Fours $92 A@a!imum of 1.00 hours in one yearB
0( 3s there any part of this super)ision being done to meet the internship reuirements of a doctoral
programQ
R S Les RS $o
3f yes, indicate the uni)ersity $92 Aplease attach a copy
of your student transcript )erifying the actual beginning and ending of the semester9uarter(
10( 'lease list the license number, date of issuance and e!piration dates if you are a '"(
'"973" O 3ssuance Date 4!piration Date
11( Do you hold any other 7icenses or certificationsQ R S Les R S $o
73"9"48T O 3ssue Date 4!piration Date
7emo of Un#erstan#ing8 3 ha)e read the counselor licensure law and understand the rules and
regulations that pertain to 'rofessional "ounselor9"linical 8esident( 3 understand that 3 will ha)e to
submit the application and fees for the '"" after satisfactory completion of the super)ision hours( 3
further understand that any person who knowingly makes a false statement on the registration form is
guilty of falsification under section 2021(1& of the #hio 8e)ised "ode, a misdemeanor of the first
degree(
Signature of Super)isee Date
1%
Part 98 To be complete# b% t"e Training !uper)isor
3nstructions to super)isor-
2fter completing this form, please return it to the super)isee who is responsible for sending it to
the 6oard(
1( 2re you a 7icensed 'rofessional "ounselor or a 7icensed 'rofessional "linical "ounselorQ
RSLes R S $o 3f yes, what is your 7icense O 1 4!piration Date 410% +9DD
2( 3f you are not a licensed counselor, what license do you holdQ
State 7icense $o(
&( 7ist your area AsB of professional competence- "ounselor Super)ision
"linical "ounseling
;( 'lease describe the nature of the super)ision to be pro)ided-
"ounseling 'racticum H Da)ier Uni)ersity
Does the scope of your practice include the diagnosis and treatment of mental and emotional
disordersQ RS Les R S $o
.( 6riefly describe your e!perience in training super)ision
2; years H "ounselor 4ducation 1 Super)ision with super)isory counselor designation from
#"S*6
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TF4L A284 B A284 $#T B 2""U82T4
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Super)isor?s Signature Date
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PROF,!!$ON5+ D$!C+O!UR, !T5T,7,NT
7on S( Criner, 'h(D(, 7icensed 'rofessional "linical "ounselor O410%
#hio 'sychology 7icense O&2;+
Da)ier Uni)ersity
"incinnati, #hio ;.20%,&22&
F FOR75+ PROF,!!$ON5+ ,DUC5T$ON
Uni)ersity Degree 8ecei)ed Dates 2ttended
The Uni)ersity of Toledo
#hio State Uni)ersity
6owling /reen State Uni)ersity
'h(D( in "ounselor 4ducation
@(2( in "ounseling
6(S( in 4ducation
10%&,%+
10%1,%2
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"linical "ounseling
"ounselor Super)ision
"areer "ounseling
'ersonal and Social "ounseling
@arriage "ounseling
"onsultation
F T($! $NFOR75T$ON $! R,GU$R,D 9H T(, O($O COUN!,+OR* !OC$5+ =ORI,R 5ND 75RR$5G,
5ND F57$+H T(,R5P$!T 9O5RD =($C( R,GU+5T,! 5++ +$C,N!,D COUN!,+OR!* !OC$5+
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!tate of O"io
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0@ =est 9roa# !treet* !uite 1@70
Columbus* O"io 33A100B1B
Tel8 /4132 344@B1A FaC8 /4132 7AD77B@
10

Active Registrations

The following classes are not officially considered complete for transcript purposes. Additional information is
available by selecting hyperlinked data.
Consultation and Supervision - COUN 642 02
Associated Term Fall Semester 200 Credits !.000
CRN "#$$% Grade Mode Standard &etter
Status Register 'un 02( 200 Course evel )raduate
Sc!edule T"pe &ecture Midterm Grade
#nstructional Met!od Traditional Grade $etail
Campus *ain Associated #nstructor +ianne S. ,arroll
Course UR
Counselin% &racticum # - COUN ''(
CRN "0%2! Grade Mode Standard &etter
Status Register 'ul 0( 200 Course evel )raduate
Sc!edule T"pe -racticum Midterm Grade
#nstructional Met!od .on/traditional Grade $etail
Campus *ain Associated #nstructor &auretta -. 0meltschenko
Course UR
Counselin% and &s"c!ot!erap" - COUN '64 0)
CRN "0%!# Grade Mode Standard &etter
Status 1eb Register Apr 0( 200 Course evel )raduate
Sc!edule T"pe &ecture Midterm Grade
#nstructional Met!od Traditional Grade $etail
Campus *ain Associated #nstructor +r. *ichelle 2all
Course UR

R**AS*+ 6,0
'rint from your 45ctive 6egistrations7 on the $y X8 'ortal
20
Xavier University
D,P5RT7,NT OF COUN!,+$NG
PR5CT$CU7 5FF$+$5T$ON 5GR,,7,NT
9,T=,,N
Site-
5ND
.5E$,R UN$E,R!$TH* Cincinnati* O(
This agreement is entered into this day of , 20 , by and between
Da)ier Uni)ersity Ahereinafter MUni)ersityN and , Ahereinafter
M:acilityNB for the purpose of pro)iding "ounseling 'racticum 4!periences for
, a /raduate "ounseling student at the Uni)ersity(
6oth parties recognize the need for counseling e!periences with bona fide students or clients at sites
pro)iding assistance to students or clients needing a wide range of ser)ices( The purpose of these
counseling e!periences is to pro)ide /raduate "ounseling super)isees opportunities to de)elop clinical
counseling skills, with the understanding that these e!periences will be integrated with course work
within the /raduate "ounseling 'rogram curriculum( 3n order to accomplish this purpose, the following
practices will be obser)ed-
1( The Uni)ersity will be responsible for establishing ob>ecti)es for the e!periences, and for
pro)iding these to the :acility Asee attachmentB(
2( The super)isee will be responsible for scheduling time to complete a minimum of ;0 direct
ser)ice hours in collaboration with the :acility( The student is e!pected to participate in a
reasonable amount of additional super)ision and training at the facility based on
recommendations of the site super)isor(
&( The Uni)ersity will pro)ide close super)ision of the super)isee according to "ouncil on
2ccreditation for "ounseling and 8elated 4ducation 'rogram A"2"84'B standards, #hio
"ounselor, Social *orker and @arriage and :amily Therapy A#"S*@:TB 6oard standards
and #hio Department of 4ducation standards( The student is reuired to meet with the
uni)ersity super)isor a minimum of one hour per week in indi)idual or triadic super)ision and
participate in group super)ision on a)erage 1(. hours per week(
;( The :acility will pro)ide super)ision of the student on site by ualified, competent, and
appropriately credentialed personnelK these persons will be designated as Mon,site
super)isors(N During practicum, on site super)ision is to be scheduled as needed and in
accordance with :acility policies(
.( The :acility will help coordinate appropriate releases of information for circumstances where
client sessions are electronically recorded( These audio or )ideo tapes are for the sole purpose
of counselor de)elopment( 3f an ethical issue arises during tape re)iew by a uni)ersity
super)isor, the on,site super)isor will be contacted by the uni)ersity super)isor(
+( #n,site super)isors will pro)ide the student additional instruction as needed for the student to
perform specific assigned tasks(
21
%( #n,site super)isors will monitor documentation of counseling sessions and )erify that all
documentation has been completed appropriately and in a timely manner and securely stored
as the practicum site(
<( The :acility will permit samples of documentation to be released to the Uni)ersity for re)iew
and to assist the student in skill de)elopment( The samples will not contain identifying
information and will be returned to the practicum site(
0( The Uni)ersity will pro)ide the on,site super)isor with a form to be used in e)aluating student
performance at mid,term and at the end of practicum( #n,site super)isors will consult with
the uni)ersity super)isor, complete the forms, and return them to the Uni)ersity, to be used in
assigning the student grades for the e!periences(
10( The Uni)ersity Aincluding both faculty and studentB agrees to respect the confidentiality of the
clients of the :acility(
11( The Uni)ersity shall pro)ide professional liability insurance co)erage in the amount of
G2,000,0009G;,000,000 for all its students, employees and agents who are assigned
super)isory or administrati)e duties in the :acility in connection with the affiliation of the
Uni)ersity?s students(
12( The on,site super)isor will return the on,site super)isor e)aluation form to the 'racticum
3nstructor in the self addressed stamped en)elope pro)ided by the Uni)ersity mailed on or
before VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV(
This agreement will be deemed in effect indefinitely unless one or both parties submit &0 days written
notice for cancellation( 3n the e)ent of cancellation, both parties will obser)e all obligations under the
agreement until the end of the Uni)ersity?s academic semester during which cancellation occurs(
Da)ier Uni)ersity thanks you for contributing to the professional de)elopment of our students in
"ounseling 'racticum( *e hope our students are able to pro)ide helpful additional ser)ice to your
school or agency?s students or clients respecti)ely(
The signatures below attest to agreement to abide by the described practices-
VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Site Super)isor 3nformation-
Site Super)isor Date
'hone numberVVVVVVVVVVVVVVVVVV
'rint $ameVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
4mailVVVVVVVVVVVVVVVVVVVVVVVVV
Super)isor "redentialsVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV

Dr( 6utch 7osey, 4d(D(, '"",S, $"" Date
Department of "ounseling
Da)ier Uni)ersity

Dr( Scott 2( "hadwick Date
'ro)ost and "hief 2cademic #fficer
22
Da)ier Uni)ersity
2&
Xavier 8niversity
GOAL OF PRACTICUM
The goal of counseling practicum is to provide graduate level counseling students
with a closely supervised clinical experience to practice professional counseling
utilizing best practice approaches and ethical decision making skills throughout the
experience.
COURSE OBJECTIVES
Students will understand and apply ethical considerations with their clients
throughout the duration of this practicum experience.
Students will understand and comply with minimal expectations for course
mandated by the Ohio Department of Education, the Ohio Counselor, Social Worker
and Marriage and Family Therapy Board, the Kentucky Counseling Board, the
Kentucky Department of Education and the Council on Accreditation for Counseling
and Related Education Programs.
Students will learn counseling techniques to successfully open, conduct, and close
a counseling interview. Students will demonstrate these skills via audiotape and
class role play. (Cf. Practicum Evaluation Supervisee Form)
Students will fully participate in a close supervised experience and develop a
working relationship with the assigned supervisor.
Students will understand the general principles and methods of case
conceptualization, assessment, and/or diagnosis of mental and emotional status.
Students will learn and apply appropriate case consultation and referral
techniques.
2;
COUN 773
Counseling Practicum
$ntent Form
T"is form s"oul# be complete# an# file# in t"e semester prior to t"e one in &"ic" %ou plan on
ta>ing t"e course'
NameJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
5##ressJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
Da% P"oneJJJJJJJJJJJJJJJJJJJJJ,)ening P"oneJJJJJJJJJJJJJ
,mailJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
$ &oul# li>e to enroll in Counseling Practicum for t"e Fall / !pring / !ummer /please circle one2
semester A@JJJJ'
Please c"ec> t"e follo&ing8
JJJ $ &ill "a)e complete# COUN 033* COUN 034* COUN 07B* COUN 431* an# COUN 44B Pre
Practicum prior to enrolling in Counseling Practicum'
JJJ $ "a)e recei)e# an# rea# t"e Counseling Practicum Handbook.
JJJ $ un#erstan# t"at $ am responsible for i#entif%ing m% o&n practicum site for access to
clients to fulfill t"e 3@ cloc> "our #irect ser)ice requirement'
7% plan for obtaining appropriate practicum site / clients is as follo&s8 /use t"e bac> of t"is
s"eet if necessar%2
Return to8
Dr' 9utc" +ose%
Clinical Coor#inator
.a)ier Uni)ersit%
Cincinnati* O"io 30A@73AA4
/0132 7301@37
lose%rK .a)ier'e#u
2.
!ample !%llabus
XAVIER UNIVERSITY
COURSE TITLE: Counseling Practicum
SEMESTER: Summer 2012
COURSE NUMBER: COUN 773
CREDIT HOURS: 3
DAY & TIME: Tuesdays and Thursdays 4:00 6:00 P.M.
LOCATION OF CLASS: Hailstones 7
INSTRUCTOR: Dr. Butch Losey, PCC-S, NCC
OFFICE LOCATION/PHONE: Hailstones 213 513-745-1037
E-MAIL ADDRESS: loseyr@xavier.edu
OFFICE HOURS: T or Th 3:00-4:00, and by appt.
Supervisors:
Donita Jackson (zumbadj@gmail.com)
Sherri Grooms (msgrooms@fuse.net)
Shelly Baxter (sbaxter@child-focus.org)
Mardi Fallon (fallonm@ucmail.uc.edu)
COURSE DESCRIPTION:
This course addresses the Clinical Instruction requirements for the 2009 CACREP
Standards for School and Community Counseling Programs. This practicum
experience involves completing recorded interviews with bona fde clients and
producing appropriate client reports and student self-evaluation forms. Note: all
students are expected to have COUN 533, COUN 536, COUN 631, COUN 579, COUN
669 successfully completed prior to enrolling in COUN 773. Students in COUN 773
must carry liability insurance purchased through the University. Students must
complete a total of 40 clock hours of counseling sessions with approximately four
clients, 8 hours of which must be recorded on CD or other device for supervisor
review. Students will also be expected to lead a group counseling experience. Progress
notes on the other sessions are due on a regular basis.
COURSE OBJECTIVES:
Students will understand crisis inter)ention and suicide pre)ention models, including the use of
psychological first aid strategies A1(/(g(B
Student will demonstrates the ability to use procedures for assessing and managing suicide risk AD(+B
Student will demonstrates appropriate use of culturally responsi)e indi)idual, couple, family, group,
and systems modalities for initiating, maintaining, and terminating counseling AD(.B
2+
Student will apply current record,keeping standards related to clinical mental health counseling
AD(%B
Student will understands counseling super)ision practices, and processes A/(1(eB
Student will understand ethical standards of professional organizations and credentialing bodies, and
applications of ethical and legal consideration in professional counseling A/(1(>B
Student will understand counselor characteristics and beha)iors that influence helping processes
A/(.(bB
Student will understand essential inter)iewing and counseling skills A/(.(cB
Student will understand counseling theories that pro)ide the student with models to conceptualize
client presentation and that help the student select appropriate counseling inter)entions A/(.(dB
Student will understand a systems perspecti)e that pro)ides an understanding of family systems
theories and related inter)entions A/(.(eB
'rinciples of group dynamics, group process components, group members? roles and beha)iors,
therapeutic factors of group work A/(+(aB and appropriate selection criteria and methods A/(+(dB
Direct e!periences in which students participate as group members in a small group acti)ity,
appro)ed by the program, for a minimum of 10 clock hours o)er the course of one academic term
A/(+(eB
Cnows the principles, models, and documentation formats of bio,psychosocial case
conceptualization and treatment planning A"(%B
Uses the principles and practices of diagnosis, treatment, referral, and pre)ention of mental and
emotional disorders to initiate, maintain, and terminate counseling AD(1B
@aintains information regarding community resources to make appropriate referrals A"2"84' :(1B
DETAILED EXPLANATION OF MINIMUM REQUIREMENTS:
CACREP Requirements
CACREP requires the following:
1. The practicum experience will include a total of 100 direct and indirect hours.
. A total of !0 hours of direct ser"ice with #ona fide clients must #e completed.
$. The practicum experience will include group counseling.
!. %roup super"ision will occur at 1.& hours per wee' o"er the course of the practicum.
&. (ndi"idual or triadic super"ision will occur one hour per wee' during the practicum.
). A final e"aluation report will #e generated on each student in practicum.
*tate of +hio and ,entuc'- .epartments of Education
/oth departments defer to CACREP standards to fulfill practicum requirement.
*tate of +hio Counselor0 *ocial 1or'er and 23T /oard
(n addition to following CACREP standards the rules for the +C*123T #oard include:
1. *tudents should register their practicum with the state on a prescri#ed form #- the
#oard within $0 da-s of #eginning the practicum.
. 1hen primar- super"ision for practicum occurs with the uni"ersit-0 a student ma- #e
super"ised #- a doctoral student0 an 4PC5 PC or 4PCC5 PCC under the instruction of an
4PCC with super"ision endorsement.
$. 1hen primar- super"ision occurs at the practicum site0 the practicum super"isor must
#e an 4PC5PC6* or 4PCC5 PCC6*.
!. 1hene"er a student is diagnosing or treating mental and emotional disorders0 a student
must #e under the super"ision of an 4PCC5PCC6*.
&. At the end of the practicum0 a student shall complete a practicum report form within $0
2%
da-s of completing the practicum.
7a"ier Policies and Requirements for Communit- Counselors
1. The uni"ersit- shall assist students in fulfilling their o#ligations to the +C*123T #oard0
,entuc'- /oard of Professional Counselors0 and +hio and ,entuc'- .epartments of
Education. The student is responsi#le for filing an- prescri#ed forms #- the state. The
uni"ersit- is not responsi#le for ensuring the prescri#ed forms are completed or "erif-
that the state #oard recei"ed the required documents. This is the sole responsi#ilit- of
the student.
. 1hen a student chooses a practicum site where the diagnosis and treatment of mental
and emotional disorders is required or the site is #illing for hours completed #- the
student at the site0 the student will "erif- that an 4PCC6* or PCC6* is a"aila#le at the
site to ser"e as the official training super"isor. This means the practicum training
super"ision agreement will #e coordinated #etween the site super"isor and the student
super"isee. The 7a"ier super"isor will ser"e as the e"aluator for the practicum
experience in cooperation with the site super"isor. (n these instances0 the student
understands that the site super"isor has the legal authorit- to determine whether a
student ma- pass the practicum course.
$. 1hen counselor trainee status is requested #- a site0 #ut does not include the diagnosis
and treatment of mental and emotional disorders nor #illing for ser"ices0 the site
super"isor ma- ser"e as the training super"isor. (f the site super"isor cannot ser"e in
this capacit-0 the uni"ersit- super"isor shall ser"e as the training super"isor to pro"ide
counselor trainee status.
In all cases, the instructor requests copies of training supervision agreements to verify who
holds primary responsibility for the counselor trainees licensure status during practicum.
REQUIRED TEXT:
Cormier, Nurius & Osborn (2009). Interviewing Strategies for Helpers: Fundamental
Skills and Cognitive Behavioral Interventions (6
th
ed). Pacifc Grove, CA:
Brooks/ Cole Publishing.
INSTRUCTIONAL METHODS AND ACTIVITIES:
Students will participate in individual and small group (1 training supervisor: 4
student ratio), and large group learning activities throughout the semester under the
direction of the faculty and training supervisors. Individual supervision with the lead
instructor is conducted on a case by case basis. The laboratory for this course is the
identifed site whereby counseling services will take place under supervision.
ASSIGNMENTS/EXAMINATIONS:
Students must demonstrate basic active listening skills in role play scenarios to
advance in this course. Failure to successfully demonstrate active listening skills as
outlined in Cormier, Nurius & Osborn may result in a recommendation to repeat the
course the following semester.
Students are required to:
2<
Signature Assignment:
1. Clinical Record 3i"e indi"idual counseling session recordings are required for
su#mission. These sessions must #e "ideo recordings 8(n case of school polic-
precluding "ideo recording0 arrangements must #e made #- the student with the
super"isor and professor9. +ne in vivo session will also #e required as part of a li"e6
super"ision session as either a mem#er of a reflection team or as a counselor trainee.
*tudents will turn in a complete client record to document the treatment for this client.
The client record will #e re"iewed #- their 7a"ier super"isor and modifications made as
suggested #- the super"isor. This is a time to :shine; with -our documentation and
e"er- step should #e made to ma'e this record the #est it can #e. The signature
assignment will #e graded on the qualit- of the clinical record and #ased on the
following ru#ric:
2et Partiall- 2et <ot 2et
*tudent completes & digital recordings
demonstrating essential inter"iewing
and counseling s'ills including
appropriate structure0 accurate
empath- responding0 paraphrasing0
and session summaries.
The student completes &
digital recordings and
inconsistentl- demonstrates
essential inter"iewing and
counseling s'ills including
appropriate structure0
accurate empath-
responding0 paraphrasing0
and session summaries.
4ess than & digital recordings
were completed. .ifficult-
demonstrating essential
inter"iewing and counseling
s'ills including appropriate
structure0 accurate empath-
responding0 paraphrasing0 and
session summaries.
The clinical record includes all required
documentation.
Progress notes do not
accuratel- reflect the num#er
of sessions and5or other
essential documentation is
inaccurate.
2a=or elements are missing
from the clinical record.
The writing clearl- demonstrates the
counselor inter"entions and client
responses.
(nconsistent documentation if
counselor inter"entions and
client responses to
inter"entions.
Counselor inter"entions and
client responses are poorl-
documented and5or a#sent from
progress notes.
A treatment plan is included and
progress notes clearl- demonstrate
that the session focused on the goals
identified in the treatment plan.
Treatment goals are unclear
and5or not written in
#eha"ioral o#ser"a#le terms.
2a=or elements of the treatment
plan are missing.
Required Assignments:
1. Cla A!!endance and Par!ici"a!ion #1$%& Class mem#ers are expected to attend
all classes and super"isor- meetings. Additional assignments will #e required of an-
student who misses two or more classes5super"ision sessions. Assignments will #e
determined on an indi"idual #asis. 2issing more than two classes ma- result in a failing
grade. Class mem#ers must participate in all class acti"ities and discussions.
'. Si(na!)re Ai(n*en! #+$%&
$. Direc! Clien! Con!ac! Each class mem#er will complete !0 hours of direct client
contact 8minimum of $0 hours indi"idual0 10 hours group9. Each indi"idual client will
ha"e a formal (nitial Client Report and Termination Report as well as Progress <otes
20
and Counselor *elf6E"aluation for each session. Each group session will ha"e a %roup
Progress <ote. 3iles must #e 'ept confidential and secured at all times #- the student.
E"er- client must ha"e a completed 7a"ier >ni"ersit- (nformed Consent #efore an-
counseling occurs and a Practicum Affiliation Agreement must #e on file for each facilit-
where sessions occur. Per the +C*123T /oard and +.E0 direct ser"ice is face to face
contact with clients. *ome credit ma- #e gi"en for orientation time with new groups.
Credit for ser"ice acti"ities other than face to face counseling will not exceed $ hours
and must #e appro"ed #- -our super"isor.
!. Cae Preen!a!ion #1$%& All class mem#ers are required to present current client
cases and situations to their super"isor- group and the full class. .iscussion of the
case0 counseling inter"entions and5or strategies will #e discussed.
&. T,eor- Pa"er #1$%& *tudents will demonstrate 'nowledge and applica#ilit- of their
personal counseling theor-. All class mem#ers will #e a#le to present and discuss their
theoretical orientation.
). S)icide Ae*en! #1$%&. *tudents will complete a suicide assessment in class
#ased on a case presented #- instructor. Assessment will #e presented to super"ision
group and turned into instructor.
?. Pro/eional Diclo)re S!a!e*en! This statement will ultimatel- #e displa-ed in
-our counseling setting. Create or update -our *tatement and turn a cop- in to -our
*uper"isor.
Client care
1. .e"elop #asic and ad"ancing counseling s'ills as continuation of Pre6Practicum.
. .emonstrate competence utili@ing #asic and ad"ancing counseling s'ills in #oth role
pla- and through recorded sessions with clients.
$. .e"elop competence in pro#lem identification0 goal setting and e"aluating goals.
!. 1hen necessar-0 offer appropriate referrals for clients #- following standards for care
prescri#ed through uni"ersit-0 agenc- or school polic-.
&. .e"elop competence documenting client sessions through progress notes and formal
assessments. 2anage a client file including all necessar- forms 8e.g. informed consent0
release of information0 outcome results9.
). Practice counseling within the guidelines of the American Counseling Association code
of Ethics and5 or the American *chool Counseling Association Code of Ethics and the
*tate of +hio or ,entuc'- Code of Ethics for professional counselors.
Counselor Supervision and Development
1. .e"elop a super"ision agreement with a counseling super"isor appointed #- the
uni"ersit-.
. (dentif- a wor' super"isor 8site super"isor9 who can assist with client emergencies and
pro"ide additional assistance at a practicum site as needed.
$. Participate in #oth informal and formal e"aluation processes in the uni"ersit- setting and
the practicum site 8when appropriate9.
!. Continue to recei"e feed#ac' and appl- feed#ac' from a super"isor in counseling wor'
with clients0 peers and colleagues.
&. Critique of student wor' usuall- includes identification of strengths and areas for
impro"ement. *tudents shall tolerate critique of their wor'. *uper"isors shall pro"ide
critique in a direct and respectful "oice.
). (nform -our uni"ersit- super"isor immediatel- of an- ris' issues with a client. This
includes0 #ut is not limited to concerns for client safet-0 suicidal ris'0 homicidal ris'0
suspicion of child or elder a#use0 drug a#use0 and ris' to commit a felon- offense.
?. (nform -our uni"ersit- super"isor immediatel- if -ou #elie"e -ou ma- ha"e crossed a
&0
#oundar- with a client or "iolated an ethical code. All #oundar- crossings and #oundar-
"iolations are managed #- the instructor on a case #- case #asis.
A. .ifferentiate #etween super"isor directi"es and super"isor suggestions. A directi"e ma-
include the phrase :in the next session0 ( need -ou toB; while a suggestion ma- #e
characteri@ed #- :in the next session0 -ou ma- want to tr- this approachB;
C. Pro"ide timel-0 accurate and complete documentation to a super"isor for re"iew. All
progress notes and documentation of client contact must #e signed #- a uni"ersit-
super"isor.
10. 4earn to self6e"aluate during the counseling process. *elf6e"aluation is a component of
super"ision that is connected to the philosoph- of the reflecti"e practitioner. The 7a"ier
>ni"ersit- .epartment of *chool and Communit- Counseling #elie"es reflecti"e
practitioners compliment the pursuit of excellence in training and education
characteristic of the uni"ersit-. *tudents shall also plan adequate personal time for rest
and relaxation during the semester. A successful practicum experience usuall- in"ol"es
good planning.

4ia#ilit-
All students practice counseling in practicum under the um#rella super"ision of the instructor.
This means the instructor holds legal lia#ilit- for student wor'. At the same time practicum is
aimed at student growth and de"elopment0 it is also a gate'eeping process for the profession.
*tudents that demonstrate impairment through emotional insta#ilit-0 mental illness0 su#stance
a#use0 other addictions0 or unethical #eha"ior ma- #e as'ed to terminate their practicum.
Complaints
All clients ha"e the right to follow a formal complaint process. This includes complaint
processes alread- in place at a school or agenc- as well as contacting the Practicum (nstructor
at 7a"ier >ni"ersit-.
All students ha"e the right to follow the formal complaint process found in the student
hand#oo'.
All site super"isors ha"e a dut- to report an- concerns a#out 7a"ier super"isees to the
>ni"ersit- instructor.
ATTENDANCE POLICY:
Graduate students are training to be professional helpers responsible for the welfare
of clients in need. Attendance in professional counseling courses is required to
evaluate the readiness and preparedness of each student to enter the profession.
Attendance and participation constitute a signifcant portion of your fnal grade.
Attendance means arriving for class on time and staying for the duration of the class.
Participation means preparing for class by reading required texts/materials and
periodically entering into class discussion.
&1
Attendance at all scheduled practicum sessions is mandatory. Students must
understand faculty carry legal liability for all clients seen by students in this course.
Therefore, scheduling vacations, weddings, and other self selected events during
scheduled classes is considered unacceptable. Students who have multiple
obligations other than Praxis exams ought to consider withdrawing and taking the
course at a later date. A student who misses more than 1 class in a semester may be
subject to possible action by the instructor, which includes, but is not limited to:
Recommendation to withdraw from the class.
Additional assignments(s) to complete the class.
Reduction in 10% of class grade.
Any other action deemed appropriate by the instructor.
&2
Sc,ed)le
.ate Content CACREP .>E
2a- A (ntroduction
Course requirements0 Paperwor'
*uper"ision 2odel0 Practices and
Processes: *uper"isor5*uper"isee Role
in class
*uper"ision Contract
Expectations
Clinical .ocumentation
Philosoph- of Counseling
.?
%.1.e
2a- 10 Communication: Content0 Thin'ing0
3eeling0
4e"els of Empath-0 2DE0
Constructionist Concepts0
(t0 1e0 Eou0 and ( statements
*tructure of 3irst *ession5ongoing
sessions
Esta#lishing a relationship
*-stems Theor- and (nter"enti"e
(nter"iewing
(nformed Consent
%.&.c
..&
%.1.=.
%.&.#
%.&.e
2a- 1& Practice 4i"e *uper"ision and Reflection
Teams in Class 8using :4u'e :scenario9
Record ,eeping *tandards: Progress
<otes and %roup <otes
%.&.c
..?
Professional
.isclosure
*tatements5*chool
Counselor /rochure
.ue
2a- 1? .iagnostic Assessment 3orm 8*herr-
%rooms9
Report 1riting
/asic Case Conceptuali@ation 8(ndi"idual
Counseling: *'ills and Techniques9:
Common Thread
Coping Pattern
Dicious C-cle
/io6ps-chosocial case conceptuali@ation
%oal *etting and Treatment Plans
%.&.d
C?
...
Read Chapter A
2a- %.&.c
%.1.e
Dideo 16.ue
4i"e *uper"ision:
3allon5Fac'son
2a- ! %.&.c
%.1.e
4i"e *uper"ision:
%rooms5/axter
2a- C 4ecture: *uicide Assessment
%roup .-namics and leadership facilitation
st-les
1.%.g.
.)
%.).a
*uicide Assessment6in
class
2a- $1 %.&.c
%.1.e
Dideo
4i"e *uper"ision:
3allon5Fac'son
Fune & No Cla
&&
Fune ? *uper"ision group to re"iew "ideos %.&.c
%.1.e
4i"e *uper"ision:
%rooms5/axter
Fune 1 Planning for (nternship: Gand#oo's
disseminated.
.e"eloping a plan for %roups
(*P
*pecial Education: (EP Process 8.onita9
G(PPA53ERPA
C?
%.1.g
%.1.=.
2id6Course
E"aluations .ue
Fune 1! %.&.c
%.1.e
Dideo $
4i"e *uper"ision:
3allon5Fac'son
Theor- Paper .ue
Fune 1C %.&.c
%.1.e
4i"e *uper"ision:
%rooms5/axter
Fune 1 Termination of *er"ices
Professional credentialing0 including
certification0 licensure
2ental Gealth and *chool Counselors
wor'ing together 8.awn9
Records 2anagement and .*26(D in the
*chool
Role /lending in *chools
Ethical (ssues
Gow to support the school counselor
..1
..?
%.1.=
Fune ) %.&.c
%.1.e
Dideo !
4i"e *uper"ision:
3allon5Fac'son
Fune A %.&.c
%.1.e
4i"e *uper"ision:
%rooms5/axter
Ful- $ %.&.c
%.1.e
Dideo &
4i"e *uper"ision:
3allon5Fac'son
Ful- & %.&.c
%.1.e
4i"e *uper"ision:
%rooms5/axter
Ful- 10 %.1.e (ndi"idual E"aluation
with .r. 4ose- H
*uper"isor
83allon5Fac'son9
Ful- 1 %.1.e (ndi"idual E"aluation
with .r. 4ose- H
*uper"isor
8%rooms5/axter9
&;
Li0e S)"er0iion Sc,ed)led Clae
!:006 Class meets in Gailstones ?
!:$06 Class #rea's up in small groups 84i"e *ession group Pre6*ession 2eeting9
&:006 Client session #egins for li"e super"ision
In!r)c!or Con!ac! In/or*a!ion
In!r)c!ion /or e*er(encie:
1. A"oid meeting with clients at odd or unusual hours0 e.g.0 *aturda- E"ening after ) p.m.
'. Do no! )e e.*ail !o a1 2)e!ion a3o)! clien!44444
$. .ecide if -ou ha"e a concern that must #e answered immediatel- or one that ma- wait
till class time.
!. Contact -our primar- super"isor. A primar- super"isor is the super"isor that is presentl-
re"iewing -our wor'.
&. (f -our primar- super"isor is una"aila#le0 contact .r. 4ose-. Allow 16 hours for a return
call.
). (f .r. 4ose- is una"aila#le0 call an- super"isor until -ou reach someone who can
respond to -our emergenc-.
?. Err on the side of safet- for -our student5client.
&.
T5EOR6 OF COUNSELIN7 PAPER
The philosoph- of counseling that -ou descri#ed in -our Practicum class is a unique and
d-namic account of -our thoughts and #eliefs a#out counseling and its impact on the human
condition. A philosoph- is not a theor-. A philosoph- ser"es as a foundation to theor-. (n this
paper0 please descri#e the counseling theor- that -ou currentl- choose to em#race and
explore for the coming semester. >se graduate le"el writing s'ills.
1. 1hat is the theor- and what are the most important characteristicsI
. 1hat attracted -ou to this theor- initiall-I
$. 1hat do -ou hope to accomplish #- using -our chosen approachI
!. Gow do -ou predict that this theor- will wor' in -our particular counseling en"ironmentI
Posing the a#o"e questions to -ourself or tal'ing a#out these with someone else will help -ou
achie"e a coherent idea a#out -our theoretical orientation at this point in time.
%i"e the papers to -our 7> super"isor. Eour super"isor will re"iew and send it to .r. 4ose-.
Ge will return the papers to -ou and -our super"isor.
&+
COUN!,+$NG PR5CT$CU7
Tec"nical Consi#erations for Recor#ing
*tarting 3all 0110 all recordings need to #e digital. The recordings ma- #e uploaded to
#lac'#oard0 -our personal 7a"ier des'top or copied to a memor- stic'.
1hen #eginning and ending the recording0 #e sure to allow se"eral seconds for the recorder to
#egin and end J there is often a time lag at these points.
Test to see that -ou are recording and the sound is good. 2an- good counseling sessions
ha"e #een lost #ecause the counselor thought a recording was #eing made. The recording
must #e audi#le to the super"isor. (f it is not audi#le0 -ou will #e as'ed to record another
session.
.o not place the recorder on heaters0 air conditioning units or in areas where it pic's up loud
distracting noises.
.o not place a digital recorder close to a computer monitor or another electronic de"ice to
a"oid possi#le interference.
Place the recorder somewhere #etween -ou and -our client. Proper placement is important so
that #oth parties ma- #e heard.
Please ha"e recordings a"aila#le #- the date assigned.
Di(i!al recordin( o/ eion8 alon( 9i!, *an- ad0an!a(e /or !,e !)den! and !,e
)"er0ior8 re2)ire addi!ional conidera!ion !o en)re con/iden!iali!- /or !,e clien!.
<e"er lea"e a "ideo file on a computer des'top or hard dri"e. (f transfer from the recording
de"ice to the we#site requires sa"ing to the computer0 delete the file after transfer and then
empt- the Rec-cle /in.
After the session has #een recorded and "iewed and e"aluated #- -our 7a"ier super"isor0 the
student will delete the session from the recording de"ice.
&%
Gui#elines for =riting $nitial Report
/Use t"is format for t"e first session &it" eac" client2
Counselee8 :irst name or initials D# $#T US4 "734$T?S 72ST $2@4
Counselor8 Lour full name(
!ource8 Fow was the client referred to youQ
Date of !ession8 VVVVVV Start TimeVVVVV 4nd TimeVVVVV
+engt" of !ession8
/in minutes2
9ac>groun# Data8 2ge, grade, family, background of family, pre)ious counseling or contacts, how
long youW)e known client, etc( 2nything that will help to identify and understand
client better( :actual data( 3f se)eral inter)iews, do background again, add what
happened since(
5ssessment Data8 $ame of tests, date, norming data, grades, etc( 3nclude any test results( 3f none
a)ailable, simply state that test data is not a)ailable(
Purpose of !ession8 Lours or client?s, or bothK the agenda, intended or de)eloped in the inter)iewK
maybe se)eral, e(g(, to discuss failing grades Ayour purposeB, to )entilate feelings
about father AclientWsB(
Description of !ession8 The narrati)e description of the inter)iew summarized( $ot a transcript, not one
paragraph but se)eral(
Counselor 5ssessment8$on,)erbal beha)ior during inter)iew, signs of ner)ousness,
your client reactions, eye contact, )oice changes, crying,
emotions e!pressed or displayed, etc( "ompare to earlier
inter)iew, if any, to before taping, after taping, etc(
Prognosis8 *hat will happen as a result of your counseling sessionQ Fow did you e!pect it
all to turn outQ 2n intelligent guess of what will happen to the client, what he or
she will do, etc( *hat you ha)e done(
&<
! 5 7 P + ,
!c"ool Counselor
$nitial Client Report
"ounselee- Tony Date of 3nter)iew- DD9DD9DDDD
"ounselor- Lour $ame Time of Session in @inutes
Source- "ounselor 8euest
62"C/8#U$D D2T2-
Tony is a second semester 0th grader( Fe is 1; years old and li)es at home with his parents( Fe has one older
brother and one older sister( Tony is an adopted son and is aware of this( Fis father, a college graduate, is
employed by the :ederal /o)ernment and his mother is a housewife( This is TonyWs second )isit with the
counselor( 're)iously @rs( C( had contacted the principal about some situations at the C( home( She told the
principal, who later shared this information with the counselor with @rs( C(Ws appro)al, that Tony may ha)e an
eating disorder and that she belie)ed that he might feel somewhat unwanted at home( She came to the principal to
seek his help Athough she asked that Tony not be informed of her )isitB( During TonyWs first session with the
counselor his academic record and some of his school problems were discussed( This inter)iew was basically
factual and the counselor hoped to facilitate a feeling of ease and comfort so that Tony might feel comfortable to
discuss some of the problems that his mother spoke about with the principal(
2SS4SS@4$T D2T2
Fis semester grades were-
4nglish " Social Studies 3 "
8eading 6 Spanish 3 "
2lgebra " Fealth 6
Fis grades for the most recent + week marking period are-
4nglish " Social Studies 3 3 AincompleteB
8eading 6 Spanish 3 D
2lgebra : Fealth "
The results of the Stanford 2chie)ement Test, taken in @arch 10<< were-
'ara( @ng( <+X %th stanine
Spelling ;+X .th stanine
7anguage +2X +th stanine
2r( "omp( 2<X ;th stanine
2r( "onc( ++X +th stanine
Soc( Studies +<X +th stanine
Science ++X +th stanine
Page 1 of 3
Client Name8
&0
'U8'#S4 #: TF4 S4SS3#$-
This inter)iew was limited by TonyWs reluctance to discuss certain issues( #riginally the counselor had hoped to
discuss his unwillingness to show his parent?s his report card but Tony was reluctant to del)e into this topic e)en
after a direct uestion by the counselor( 2s a result the counselor belie)es that the inter)iew was really too
unstructured and that, upon relistening to the tape, there really seemed to be no purpose to this session e!cept to
let Tony talk about a lot of different things(
D4S"83'T3#$ #: TF4 S4SS3#$-
The inter)iew began with a discussion of his recent academic results, especially his algebra grade( Tony seemed
to want to stay on the factual le)el of his report( Fe stated that he put much emphasis on grades, perhaps too
much, but that he did not much )alue the alpha code teachers can use to comment upon classroom beha)ior and
academic work(
*hen approached about not showing his report card to his parents, Tony hesitated to respond and then switched
back to his academic record( *hen the counselor asked Tony if he would rather not talk about not showing his
report card, he briefly talked about the reaction he might get at home( 6ut then he began to discuss is fatherWs
educational background which seemed to be an ob)ious attempt to be e)asi)e as there had been nothing
mentioned about this earlier( The counselor felt that this was not going to yield any information and instead of
terminating the inter)iew or keeping on this topic, he instead asked Tony if he had gi)en any thought about future
plans(
The boy spoke at length about how he was interested in life,sa)ing and emergency work, especially because of his
fatherWs in)ol)ement in the local )olunteer life suad( Tony discussed his most recent si! weeks in Fealth class
when first,aid was studied( 6ecause of is interest he was disappointed in this course because he considered the
atmosphere to be )ery poor for learning( Fe thought that the instructor was, in some ways, not as skilled as he
ATonyB was in first,aid(
2s the inter)iew ended, the counselor attempted to re,focus Tony on his report card and return the inter)iew to
this original topic( Tony simply said that he knew he had to show it to his parent sooner or later( 2pparently he
considered this a sufficient response, as he got up at this point and began to walk towards the door(
"#U$S47#8 2SS4SS@4$T-
#ne aspect of TonyWs beha)ior the counselor thought significant was the tone of his )oice during the inter)iew( 3t
was )ery tight and sounded Yner)ous(N Se)eral times he sounded as if he were ha)ing difficulty speaking(
@oreo)er, he was constantly sniffing his nose and rubbing his eyes( *hile he did not cry during the inter)iew, the
counselor thought that his )oice belied a real sense of ner)ousness and discomfort( Tony stated that he had sinus
trouble and that was why his nose was running and his eyes were watering( Tony had more direct eye contact
during this second )isit but still sometimes a)oided looking at the counselor(
Tony was cleanly dressed, though his appearance at times, is somewhat unkempt( Fe is slightly obese(
Page A of 3
;0
Client Name8
'8#/$#S3S-
6ased on the results of the inter)iew, the counselor feels that Tony does ha)e some concerns which he is not
re)ealing( "ertainly his grades and academic performance are important to him, but these seem to be only part of
the problem( @oreo)er, the counselor belie)es that the academic problems ha)e been sufficiently dealt with Aa
tutor for him in Spanish, a restructuring of his classes for ne!t yearB so that if they were his ma>or concerns,
TonyWs recent inter)iew is difficult to interpret, especially his ner)ousness( 'erhaps Tony is unable to feel
comfortable with this particular counselor( 2 possible suggestion would be that someone else in the department
talks with him( 6ased on two inter)iews with Tony, plus what was re)ealed by his mother, this counselor feels that
Tony needs to talk more about concerns other than grades( Fowe)er, he gi)es no indication that he would be
willing to do so(
Page 3 of 3
;1
! 5 7 P + ,
!elf ,)aluation
Ato be completed after e)ery session with a clientB
Counselor Name Lour $ame
Client $nitials T
Date of $nter)ie& JJJJJJJJJJJJJJJJJJJJJ
Client !ession Number JJJJJJJJJJJJJJJJJJJJJ
T"ings $ #i# &ell in t"is inter)ie& inclu#e- A/i)e specific e!amplesB
3 attempted to be supporti)e of the client and respond to his significant statements( 3 demonstrated
interest in helping Tony and used humor to help him feel at ease during the session(
7% plans to impro)e in t"e neCt session inclu#e- A/i)e specific e!amplesB
2fter listening to the recording, 3 felt that 3 did not sufficiently e!plore why Tony had not shown his
report card to his parents( @oreo)er, 3 felt that 3 left the entire inter)iew too unstructured which allowed
Tony the opportunity to a)oid discussing this situation( 2t least twice 3 could ha)e pursued this topic
further in a non,threatening manner( :or e!ample, when Tony picked up his report card and started to
talk about it rather than discuss the idea introduced by me, 3 let Tony a)oid responding to the topic at
hand( The second instance occurred when Tony switched to his fatherWs school background( 3 made a
brief attempt to re,direct him to the original topic, but again Tony a)oided this(
3n summary, while the inter)iew ga)e Tony a chance to talk about some concerns, grades, and aspects of
teacher beha)ior in the classroomK 3 felt that the inter)iew did not achie)e its stated purpose( This lack of
success was directly related to my dependence upon closed uestions rather than acti)e listening skills(
3 need to decrease the use of closed ended uestions and increase acti)e listening skills(
Guestions for m% super)isor inclu#e8
3 am struggling with the difference between open ended and closed ended uestions( 3t seems the client
needs more direction from me( *hat is my role with this client when the parent are reuesting particular
resultsQ
;2
! 5 7 P + ,
Communit% Counselor
$nitial Client Report
Counselee8 6eth Time of !ession in 7inutes-
Counselor8 Lour $ame
!ource8 "ounselor reuest
Date of $nter)ie&8
9ac>groun# Data8 The client is a 10,year,old "aucasian female who is currently in her first year of
college in "incinnati( She is from a small town in northeastern #hio and she
recently mo)ed to "incinnati( She li)es with her aunt(
5ssessment Data8 The client has ne)er been in counseling before and therefore a psychological
assessment has not been completed( She stated that she is currently on academic
probation from the uni)ersity because of her first semester grades( She is also
failing her math course this semester(
Purpose8 This inter)iew allowed the counselor to de)elop skills practicing se)eral
techniues( The client used this time to work through her feelings in regards to
school and her life at this point( She knows she is not succeeding in the school
arena, yet she feels she has learned so much in the past year about herself( The
client is torn between telling her parents that she is not doing well in school
and facing the disappointment that they may e!press to her(
Description8 The client discussed the pressure that she places upon herself to do well in college
as well as the pressure she feels from her parents to e!cel( The client seemed )ery
introspecti)e throughout the tape and appeared to be aware of her emotions and
e!pectations for herself( Fer )erbal skills allowed her to e!press herself in a
meaningful manner on a consistent basis( The client is e!ploring both negati)e
and positi)e points in her situation and she is willing to assess the )alidity of each(
*hen the client first began the inter)iew, she spoke mostly of the negati)e aspects
of her school situation( Fowe)er, as the inter)iew continued, her focus turned to
her accomplishments since mo)ing to "incinnati( These include finding
a peer group and simply taking care of herself( The pride she feels in meeting
these non,academic goals was e)ident by the manner in which her face lit up in
discussing them( Throughout the course of this inter)iew the client was able to
realign her focus to some of the possibilities that lie ahead once she faces her
parents? disappointment(
Page 1 of A
;&
Client Name8
5ssessment8 The client is an attracti)e woman but she does appear younger than her stated ageK
she is )ery small in stature and physiue( She was dressed casually for the
inter)iew and was )ery neat and well groomed( The client did appear ner)ous at
the start of the inter)iew as e)idenced by her fiddling with her car keys, which she
put down and stated, M3 can?t stop messing with these(N She was, howe)er, )ery
cooperati)e and willing to engage with this counselor( 2s the session continued,
the client seemed to rela! and her hands rested on her lap( The client appears to be
able to process her thoughts in a logical manner(
Prognosis8 6ased on the inter)iew, it is likely that the client will tell her parents about her
situation in school soon( The situation has been troubling the client as e)idenced
by the distress she showed when she described her predicament( She appears to
desire a resolution but she said she wants to make this decision on her own(
Therefore, gi)en the client?s discussion, it seems that she may decide her future
plans before talking to her parents so that their opinion does not influence her as
much( The client emphasized the great )alue she places upon the independence
she has gained by li)ing away from home and she especially does not want to let
that disappear from her life(
;;
A of A
! 5 7 P + ,
!elf ,)aluation for Ei#eo !essions
Counselor Name JJJJJJJJJJJJJJJJJJJJJ
Client $nitials JJJJJJJJJJJJJJJJJJJJJ
The counselor impro)ed her skills in this session by using acti)e listening more often( 3ncreasing these
responses is the counselor?s goal for future sessions( 3 tried limiting my habitual use of the word MUmN
and think that 3 impro)ed during this inter)iew(
3 tended to ask closed uestions( 3 am learning to reconsider and assess if the answer to those uestions
will be helpful in any way( Using acti)e listening was difficult because it seemed that the inter)iew was
simply going in circles at some points( 2t those times, 3 wanted to use another inter)ention but was at a
loss for what to do(
3 noticed that 3 still ha)e the tendency to use the word MrightN to affirm what the person is saying( 3
caught myself a couple of times after 3 had said it and realized that it >ust flows out as easily as simply
nodding in agreement(
3n past sessions 3 was ner)ous and watched the clock for the entire session( Fowe)er, in this tape 3 went
to the other e!treme( 3 forgot to look at the clock at the start of the session and soon realized 3 did not
know the ending time( The inter)iew actually lasted about .0 minutes( The time on the tape seemed to
go by much faster than anticipated( 'erhaps 3 was less ner)ous and therefore, the time elapsed more
naturally(
/oals for the ne!t session include assisting the client in how she may wish to approach her parents with
this
Fow can 3 begin to establish therapeutic goals with the client when the client seems to be talking about
so many issues at one timeQ
;.
;+
Uni0eri!- S)"er0ior.S)"er0iee A(ree*en!
Xa0ier Uni0eri!-
Prac!ic)*
This agreement ser"es as "erification and a description of the uni"ersit- #ased counseling
super"ision pro"ided #- KKKKKKKKKKKKKKKKKKKKKKKKKKK 8:>ni"ersit- *uper"isor;9 to
KKKKKKKKKKKKKKKKKKKKKKKKKKKKK 8:*uper"isee;90 a %raduate Counseling *tudent enrolled
in Practicum at 7a"ier >ni"ersit- for the Summer semester 2012.
(. Purpose0 %oals0 and +#=ecti"es:
a. 2onitor and ensure welfare of clients seen #- *uper"isee
#. Promote de"elopment of *uper"iseeLs professional counselor identit- and competence
c. 3ulfill academic requirement for *uper"iseeLs practicum
d. 3ulfill requirements in preparation for *uper"iseeLs pursuit of counselor licensure
((. Context of *er"ices:
a. +ne 819 cloc' hour of indi"idual or group super"ision wee'l- #eginning Fune ? and
ending Ful- 1th. Exceptions to the one hour rule will #e made #- the Practicum
(nstructor0 Dr. :)!c, Loe-
#. (ndi"idual super"ision will #e conducted on the campus of 7a"ier >ni"ersit-. Phone or
we# #ased super"ision will #e utili@ed as needed.
c. Cogniti"eJ#eha"ioral methods0 interpersonal process recall0 progress notes0 and role
pla-s will #e used in super"ision
d. Regular re"iew of written clinical documentation0 counseling digital "ideo and li"e6
super"ision in wee'l- indi"idual super"ision
(((. 2ethod of E"aluation:
a. 3eed#ac' will #e pro"ided #- the *uper"isor during each indi"idual or group session0
and a formal e"aluation0 using the Practicum *uper"isor or *uper"isee E"aluation
standard e"aluation form will #e conducted at the conclusion of the Summer semester
#. *pecific feed#ac' pro"ided #- *uper"isor will focus on *uper"iseeLs demonstrated
counseling s'ills and clinical documentation.
c. *uper"isee will e"aluate *uper"isor at the close of the *ummer semester0 using the
.epartment of Counseling standard e"aluation form for e"aluating super"isors. A
narrati"e e"aluation will also accompan- the o#=ecti"e e"aluations
(D. .uties and Responsi#ilities of *uper"isor and *uper"isee:
Supervisor
a. Examine client presenting complaints and treatment plans
#. Re"iew "ideos of *uper"iseeLs counseling sessions #oth during and5or outside of
regularl- scheduled super"ision sessions
;%
c. *ign off on all client documentation
d. Challenge *uper"isee to =ustif- approach and techniques used
e. 2onitor *uper"iseeLs #asic attending s'ills
f. Present and model appropriate directi"es
g. (nter"ene when client welfare ma- #e at ris'
h. Ensure American Counseling Association 8ACA9M American *chool Counseling
Association 8A*CA9M and +hio Counselor0 *ocial 1or'er and 2arriage and 3amil-
Therapist /oard Code of Ethics are upheld.
i. *uper"isor will 'eep (nstructor appraised of student progress and challenges throughout
the semester
*uper"isee:
a( >phold C, SC and !CS"#$% &oard Code of Ethics
#. Re"iew counseling session "ideos in preparation for wee'l- super"ision. Derif-
recording is clearl- audi#le for #oth super"iseeLs "oice and clientLs "oice
c. Complete all progress notes within !A hours of session
d. /e prepared to discuss all client casesNha"e client files0 current and completed client
case notes0 and counseling session recordings read- to re"iew in wee'l- super"ision
sessions
e. %i"e super"isor chart to read and re"iew notes. *uper"isee ma- 'eep a cop- of notes
as needed to continue sessions.
f. Fustif- client case conceptuali@ations made and approach and techniques used
g. Consult with Counseling Center staff and *uper"isor in cases of emergenc-
h. (mplement super"isor- directi"es in su#sequent sessions
C. *uper"iseeLs 4earning +#=ecti"es 'optional( to be completed by Supervisee and reviewed
by Supervisor):
+#=. 1:KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK
+#=. :KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK
+#=. $:KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK
D. Procedural Considerations:
a. *uper"iseeLs written case notes and treatment plans and audio recordings will #e
re"iewed and e"aluated within a wee' time frame #etween super"ision sessions
#. (ssues related to *uper"iseeLs professional de"elopment will #e discussed
;<
c. *essions will #e used to discuss issues of conflict and failure of either part- to a#ide #-
directi"es outlined in this agreement. (f concerns of either part- are not resol"ed in
super"ision0 .r. 4ose- will #e consulted
(n e"ent of emergenc-0 *uper"isee is to contact *uper"isor at the office0
8 9 KKKKKKKKKKKKKKKKKKKKKK or at home0 8 9 KKKKKKKKKKKKKKKKKKKKKK or #- cell
phone0 8 9KKKKKKKKKKKKKKKKKKKKKKKKKKKKK.
;0

Progress Notes
!elf,)aluation
Termination Report
Students are reuired to complete progress notes for each counseling session after the initial session
report( These forms are used for the 2
nd
session and thereafter until termination(
These progress notes ser)e two purposes( #ne is to monitor the client?s well,being( The other is to ser)e
as a log of the counselor9client interactions(
The termination report ends the legal liability that you, your practicum site and Da)ier Uni)ersity hold
for your client(
.0
Pro(re No!e
Client (nitials KKKKK *ource of Referral KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK
Counselor <ame KKKKKKKKKKKKKKKKKKKKK .ate of (nter"iew KKKKKKKKKKKKKKKKK
Client *ession <um#er KKKKK 4ength of *ession 8minutes9KKKKKKKK Time of .a- KKKKKKKKK
Decri"!ion:
/rief summar- of the inter"iew content.
Ae*en!:
The counselorLs e"aluation of the clientLs current situation and5or #eha"iors.
Re"one:
(n what wa- did the client respond to the counselorI The inter"entionI
Trea!*en! Plan:
The next steps the counselor will ta'e 6 Continued sessionsI Client homewor' assignmentsI *ee'
consultationI ReferralI
KKKKK
%raduate Counseling *tudent .ate 7a"ier *uper"isor .ate
.1
Group !ession Note
/roup $ame- VVVVVVVVVVVVVVVVVVVV Date- VVVVVVVVVVVVVVVV
"ounselor $ame- VVVVVVVVVVVVVVVVV Session O-VVVVVVVVVVVV
Session start time- VVVVVVVV Stop time- VVVVVVVVV
3ssues9concerns9topics discussed in group
session-VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
"ounselor 2ssessment of /roup 'rocess Ai(e(, dynamics and inter)entionsB, and content Ai(e(, client
responsesB-VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
"ounselor 2ssessment of Self- Ai(e(, what counselor did well, areas in need of
impro)ementB-VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
'lan :or $e!t /roup Session 2nd9#r 8ecommendations for
treatment-VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
/roup
2ttendees-VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Date- VVVVVVVVVVVVVVVVVVV
"ounselor Trainee
VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Date- VVVVVVVVVVVVVVVVVVV
Super)isor
.2
!elf ,)aluation for Ei#eo !essions
Counselor Name JJJJJJJJJJJJJJJJJJJJJ
Client Name JJJJJJJJJJJJJJJJJJJJJ
.&
! 5 7 P + ,
Termination Report
"ounselee- Tony Termination Date- DD9DD9DD
"ounselor- Lour $ame
SU@@28L #: "#U$S473$/
Tony completed si! sessions of counseling with this counselor including one family consultation with
Tony and his mother( Tony was originally referred to the counselor by his mother through the school
principal( 3nitial concerns included the mother?s report that Tony may ha)e an eating disorder, that he
may feel unwanted at home and that he is ha)ing difficulty in a few courses( 6ased on an initial
assessment the following goals were established for counseling with Tony- A1B 2ssist Tony in de)eloping
a method to discuss his grades with his parents A2B 2ssess progress in academic performance following a
& week tutoring period A&B 'ro)ide a forum for Tony to talk about any concerns that may be impacting
his school performance(
"#U$S47#8 3@'84SS3#$S
Tony is a 1; year old second semester 0
th
grader e!hibiting symptoms of a mild depression and a
moderate an!iety disorder( The mother?s concern that Tony has an eating disorder may need further
consideration by a physician( Fe reports a decreased appetite and may not be eating appropriate foods(
Tony e!periences periods of restlessness during the day both at home and school( Fe finds that he
becomes easily fatigued and has difficulty concentrating in classes( :inally, he reports periods of
irritability inconsistent with beha)ior prior to this year( :or e!ample, Tony tore up his report card when
he saw a grade less than a 6, he destroyed model cars that he built in the past year and freuently locked
himself in his room( 2lthough many of the symptoms described are not atypical for a 1; year old male,
the symptoms are less characteristic of Tony and ha)e persisted for the last si! months( 3n addition,
Tony indicates he wishes that he felt more moti)ated to complete his school work and en>oy the
companionship of friends and family( Fe does report he feels lo)ed by his parents, howe)er, he does not
belie)e his father understands him(
'8#/84SS T#*28D /#27S
Tony became more at ease discussing his concerns with this counselor by the &
rd
session( The following
progress was achie)ed toward specific goals- A1B The counselor met with Tony and his mother for a
family consultation( Tony agreed to allow his parents to open his grade report at the end of this
semester( Fis mother agreed to talk with Tony about his grades and stated she and his father would not
belittle him, rather try to understand what he needs to do to impro)e( A2B Tony remains on track with
tutoring sessions for courses where he has e!perienced the most difficulty( A&B Tony disclosed he has a
poor self image, coupled with feelings of an!iety about dating girls and de)eloping friendships with the
same se!( Fe admitted there is some pressure from his father to be more masculine and athletic
although Tony reports his father is )ery o)erweight and lacks self control with his diet( Tony wants to
be more physically acti)e and attracti)e to the opposite se!( Tony has made plans to consult with an
athletic trainer who is a friend of his older brother(
842S#$ :#8 T48@3$2T3#$ 2$D 84:48827S
.;
This school counselor agreed to meet with Tony for si! &0 minute sessions and offer a referral for further
counseling if necessary( The student?s mother has made arrangements for Tony to meet with a pri)ate
practice counselor and his family physician to further assess a possible depressi)e and9or an!iety
disorder, and rule out any type of eating disorder( The school counselor will be a)ailable for
consultation with the clinical counselor and brief appointments related to Tony?s progress in classes(
'8#/$#S3S
Tony?s decline in academic performance is most likely influenced by social and de)elopmental
concerns, mild pressure in his home en)ironment and possible de)elopmental depression and an!iety(
"ontinued counseling and medical inter)ention will be helpful in alle)iating symptoms that may inhibit
academic and social performance at school( The prognosis for Tony is good with continued use of
family and social ser)ice support systems(
VVVVVVVVVVVVVVVV VVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVVV
"ounselor Signature and "redentials Date
VVVVVVVVVVVVVVVVVVVVVVV VVVVV VVVVVVVVVVVVVVVVVVVVV
Super)isor Signature and "redentials Date
..
5ssessment of Performance
*ritten assessment of student performance in 'racticum is recorded on the following forms-
1( Super)isee 4)aluation :orm
2( Da)ier Super)isor 4)aluation :orm
&( Site Super)isor 4)aluation :orm
The Da)ier Super)isor 4)aluation :orm is identical to the super)isee e)aluation form, so it is not
included in the handbook(
The student will use the following Super)isee 4)aluation :orm as a guide for e)aluation criteria in the
course( The student will complete this e)aluation form at the end of the semester as part of the formal
e)aluation process for the course( Super)isors will complete a similar form for the student( 8esults will
be discussed in final meeting between the instructor, super)isee and super)isor(
@id term e)aluations are informal discussions between the super)isor and super)isee about their skill
performance following the completion of the third recording(
The student will recei)e a self addressed stamped en)elope from the instructor mid semester( The site
super)isor will return the Site Super)isor 4)aluation :orm )ia mail to the course instructor to be
included in the student?s o)erall course e)aluation(
.+
Mid-Course Evaluation
(Completed by Supervisee and Site Supervisor)
1( :ar below e!pectations,needs impro)ement, a concern
2( 6elow e!pectations,needs some impro)ement to meet standards
&( 2cceptable,meets standards at a)erage le)el for 'racticum 33 students
;( 2bo)e e!pectations,performs abo)e a)erage le)el for 'racticum 33 students
$2Z$ot applicable
Skill 2rea
'rocedural
VVVV #pens session smoothly
VVVV 'ro)ides informed consent
VVVV 3dentifies important concerns in the session
VVVV 3dentifies risk issues and reports to super)isor
VVVV :ollows policy and procedures of an educational or agency setting regarding harm to others,
substance abuse, and child abuse(
VVVV 2bility to end session smoothly
VVVV 'ro)ides appropriate referrals when necessary
5ttending %ehavior
VVVV "ounselor demonstrates interest in client
VVVV 2bility to establish a rhythm and pace compatible with the client
VVVV "ounselor is able to manage silence appropriately
9istening 6esponses
VVVV "larification
VVVV 'araphrase
VVVV 8eflection of feeling A4mpathyB
VVVV Summarization
:nfluencing 6esponses
VVVV #pen Juestion
VVVV "losed Juestion
VVVV 3nterpretation A2d)anced 4mpathyB
VVVV 3nformation /i)ing
VVVV 3mmediacy
VVVV Self Disclosure
VVVV "onfrontation9 'erception "heck9 "hallenging Statement
!ounselor and !lient 6elationship
VVVV 2bility to mi! and balance responses in session
VVVV Demonstrates patience with client
VVVV 4stablishes a collaborati)e working relationship with client
VVVV 2bility to set goals with client and mo)e toward action in problem sol)ing(
VVVV 2bility to facilitate decision making
VVVV 2bility to e)aluate counselor client relationship
.%
'lease comment on the following aspects of 'racticum 33 as these relate to your e!perience(
2pplicability of classroom discussion=
8ele)ance of topics co)ered in classroom sessions=
Topics you might like to co)er=
*orkload=
Super)ision group work=
3ndi)idual super)ision Ain person, recorded sessionsB=
*hat you like=
*hat you would like to change Aand suggestions for impro)ementB=
2ny other comments, thoughts, ideas, complaints=
.<
XAVIER UNIVERSI!
"RACICUM EVA#UAI$N
SU"ERVISEE %$RM
'racticum super)isee nameVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
Date of e)aluationVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
Da)ier Super)isorVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
'racticum SiteVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
#n,Site Super)isor $ameVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
3nstructions- Lour super)isor will be asked to complete an e)aluation form designed to assess your
performance during your practicum( This form is pro)ided to you to help you assess your own
performance( 3t is essentially identical to the one gi)en to your super)isor( The form will become part
of your permanent record for this course and may be considered in assigning a grade for practicum(
'lease answer each item using the scale pro)ided( Space is pro)ided following each category group for
specific comments( There is also space at the end of the form for general comments( 3f you feel it
would be helpful to put anything into conte!t from the outset, please feel free to do so-
2nswer code
$2- $ot applicable or $ot enough information to form a >udgment
1( :ar below e!pectations,needs impro)ement, a concern
2( 6elow e!pectations,needs some impro)ement to meet standards
&( 2cceptable,meets standards at a)erage le)el for 'racticum 3 students
;( 2bo)e e!pectations,performs abo)e a)erage le)el for 'racticum 3 students
I& 'asi( Course Re)uirements
VVVV 2rri)es on time consistently
VVVV 3nforms super)isor and makes arrangements for absences
VVVV "ompleted assigned course papers on time
VVVV 8esponsi)e to norms for professional beha)ior in a uni)ersity setting
VVVV Demonstrates e)idence of reading te!t by completing assignments
VVVV 'articipated in role play e!ercises as needed
"omments-
Suggested areas for further study-
.0
II& Et*i(al A+areness and Condu(t
VVVV Cnowledge of general ethical guidelines
VVVV Cnowledge of ethical guidelines for agency or school placement
VVVV Demonstrates awareness and sensiti)ity to ethical issues
VVVV 'ersonal beha)ior is consistent with ethical guidelines
VVVV "onsults with super)isor about ethical issues if necessary
"omments-
III& ,no+led-e and #earnin-
2( Cnowledge of "lient 'opulation
VVVVCnowledge of client population at beginning of practicum
VVVVCnowledge of client population at end of practicum
6( Cnowledge of Treatment 2pproaches
VVVVCnowledge of treatment approaches at beginning of practicum
VVVVCnowledge of treatment approaches at end of practicum
"( Cnowledge of Treatment Setting
VVVVCnowledge of treatment setting at beginning of practicum
VVVVCnowledge of treatment setting at end of practicum
D( 7earning
VVVV8ecepti)e to learning when new information is offered
VVVV2cti)ely seeks new information from super)isor and peer group
VVVV2bility to learn and understand new information
VVVVUnderstanding of concepts, theories, and information
VVVV2bility to apply new information in a school or clinical setting
"omments-
+0
IV& S.ill /evelopment
.( :ar below e!pectations,needs impro)ement, a concern
+( 6elow e!pectations,needs some impro)ement to meet standards
%( 2cceptable,meets standards at a)erage le)el for 'racticum 3 students
<( 2bo)e e!pectations,performs abo)e a)erage le)el for 'racticum 3 students
Skill 2rea
'rocedural
VVVV #pen session smoothly
VVVV 'ro)ide informed consent
VVVV 3dentify important concerns in the session
VVVV 3dentifies risk issues and reports to super)isor
VVVV :ollows policy and procedures of an educational or agency setting
regarding harm to others, substance abuse, and child abuse(
VVVV 2bility to end session smoothly
VVVV 'ro)ides appropriate referrals when necessary
5ttending %ehavior
VVVV "ounselor demonstrates interest in client
VVVV 2bility to establish a rhythm and pace compatible with the client
VVVV "ounselor is able to manage silence appropriately
9istening 6esponses
VVVV "larification
VVVV 'araphrase
VVVV 8eflection of feeling A4mpathyB
VVVV Summarization
:nfluencing 6esponses
VVVV #pen Juestion
VVVV "losed Juestion
VVVV 3nterpretation A2d)anced 4mpathyB
VVVV 3nformation /i)ing
VVVV 3mmediacy
VVVV Self Disclosure
VVVV "onfrontation9 'erception "heck9 "hallenging Statement
!ounselor and !lient 6elationship
VVVV 2bility to mi! and balance responses in session
VVVV Demonstrates patience with client
VVVV 4stablishes a collaborati)e working relationship with client
VVVV 2bility to set goals with client and mo)e toward action in problem
sol)ing(
VVVV 2bility to facilitate decision making
VVVV 2bility to e)aluate counselor client relationship
+1
V& Response to Supervision
VVV 'repared for super)ision meetings
VVV 8ecepti)e to feedback from super)isor
VVV Understands information communicated in super)ision
VVV Successfully implements suggestions from super)isor
VVV 2ware of areas that need impro)ement
VVV *illingness to e!plore personal strengths and weaknesses
"omments-
VI& Intera(tions 0it* Clients
VVVV 2ppears comfortable interacting with clients
VVVV 3nitiates interactions with clients
VVVV "ommunicates effecti)ely with clients
VVVV 6uilds rapport and respect with clients
VVVV 3s sensiti)e and responsi)e to client?s needs
VVVV 3s sensiti)e to cultural differences
VVVV 3s sensiti)e to issues of gender differences
"omments-
VII& Intera(tions 0it* Collea-ues
VVVV 2ppears comfortable interacting with other practicum colleagues
VVVV 3nitiates interactions with colleagues
VVVV "ommunicates effecti)ely with colleagues
VVVV 4ffecti)ely con)eys information and e!presses own opinions
VVVV 4ffecti)ely recei)es information and opinions from others
"omments-
+2
VIII& /o(umentation
VVVV 8eliable and accurate record keeping
VVVV *ritten or )erbal reports are accurate and factually correct
VVVV *ritten or )erbal reports are presented in a professional manner
VVVV 8eports are clinically useful
VVVV Documentation is timely Aought to be completed within 2; hours of appointmentB
"omments-
#)erall, what would you identify as your strong pointsQ
*hat would you identify as areas in which you need to impro)eQ
Do you belie)e you are prepared for 'racticumQ
Do you belie)e you are ready to continue study in the Department of "ounseling at Da)ier Uni)ersityQ
Super)isee signature-VVVVVVVVVVVVVVVVVVVVVVVVVV Date-VVVVVVVVVVVVVVVVVV
+&
.a)ier Uni)ersit%
!ite !uper)isor Practicum Final ,)aluation Form
Super)isor $ame- DU Student $ame-
please print& (please print&
Super)isor Signature-
2ddress-

'hone- Date-

'lease complete the following by placing a checkmark in the appropriate column.
5t present t"e practicum stu#ent un#er m% super)ision8 /##D :238 '##8 $92
1( Fas an awareness of his9her own strengths and limitations
2( Uses super)ision for personal and professional growth(
&(
Fears and understands the super)isor?s feedback during
super)ision(
;(
#penly and appropriately communicates with the
super)isor(
.( 8eadily seeks super)isory direction when needed(
+( 3nitiates appropriate working relationships with clients
%(
:ollows ethical procedures Ae(g( confidentialityB in client
relationships and in regard to organization issues(
<( 3s able to define appropriate counseling goals with clients(
0( 3s accepting of client differences(
10(
"an articulate and pro)ide a rational for counseling
approaches(
11( Ceeps all reuired records up to date(
#T48277- Les $o
12( Successfully fulfilled practicum responsibilities(
1&( 3 ha)e a concern, please contact me to discuss(
+;
.5E$,R UN$E,R!$TH
,E5+U5T$ON OF PR5CT$CU7 !UP,RE$!OR
"#U8S4 $2@4- "ounseling 'racticum $N!TRUCTOR- Dr( 6utch 7osey
!,7,!T,R-VVVVVVVVVV
Super)isor $ame-VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
!UP,RE$!$ON GROUP ,E5+U5T$ON
1( #)erall, what were the strengths of the super)ision group sessionsQ
2( Fow could the super)ision group sessions be impro)edQ
!UP,RE$!OR ,E5+U5T$ON
1( *hat were the strongest aspects of this super)isorQ
2( *hat changes or impro)ements would you recommend for this super)isorQ 6e specific(
P+,5!, R5T, T(, FO++O=$NG
Felpfulness of super)isor feedback-
VVVVVTery helpful VVVVVFelpful VVVV@inimally helpful VVVV$ot helpful at all
'lease e!plain-
Felpfulness of super)isor,led acti)ities and role plays-
VVVVVTery helpful VVVVVFelpful VVVV@inimally helpful VVVV$ot helpful at all
'lease e!plain-
Ao)erB
Please list an% a##itional comments* concerns* or fee#bac> "ere'
+.
Prac!ic)* S!)den! S)r0e-
De*o(ra",ic In/or*a!ion
*lease provide the following demographic information(
7ender
;;;;;; 2ale KKKKKK 3emale
A(e
KKKKKK 06& KKKKKK )6$0 KKKKKK $16$& KKKKKK $)6!0 KKKKKK !0O
Pro(ra*
;;;;;; Communit-52ental Gealth Trac'
KKKKKK *chool Counseling Trac'
Prac!ic)* Si!e
KKKKKK +n6campus counseling center KKKKKK *chool
KKKKKK Communit-5agenc- KKKKKK +ther 8please specif-9
E<"erience in !,e /ield #co**)ni!- *en!al ,eal!, or c,ool&.
( ha"e KKKKKK -ears experience in the field.
Fo# Title KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK
(f no experience in the field0 please indicate past or current profession:
KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK
++
Prac!ic)* S!)den! S)r0e-
To the practicum student:
This sur"e- is helpful in determining practicum studentsL perceptions of their experiences0
needs and concerns as #eginning clinicians. Please ta'e a few moments to answer the
following questions.
Using the following scale, please rate the following statements as they relate to you:
= > ? ' 1
Al9a- Mo! o/ !,e !i*e Occaionall- Seldo* Ne0er
1. ( find that ( am "er- anxious #efore a session with a client. & ! $ 1
. ( dou#t m- a#ilities to #e a competent and effecti"e counselor. & ! $ 1
$. ( experience significant anxiet- #efore and5or during group sessions. & ! $ 1
!. ( ha"e trou#le winding down after a da- at m- practicum site. & ! $ 1
&. ( tend to ruminate a#out clients0 wondering if ( did or said the :right; thing. & ! $ 1
). ( ha"e difficult- asserting m-self with clients. & ! $ 1
?. ( internali@e the stress ( experience as a #eginning counselor. & ! $ 1
A. ( ha"e a positi"e support s-stem to help me manage m- stress. & ! $ 1
Below is a list of potential educational topics to be taught during future practicum courses.
Please rate the degree of helpfulness of the topics using the following scale:
= > ? ' 1
E<!re*el- 5el"/)l 5el"/)l So*e9,a! 5el"/)l No! @er- 5el"/)l No! 5el"/)l a! all
1. Coping strategies for managing stress. & ! $ 1
. Coping strategies for managing anxiet-. & ! $ 1
$. Asserti"eness training resources. & ! $ 1
!. Time6management techniques and resources. & ! $ 1
&. .e"eloping a support networ'. & ! $ 1
). Techniques for managing self6dou#t and increasing self6efficac-. & ! $ 1
?. *elf6exploration exercises. & ! $ 1
A. Communit- support resources. & ! $ 1
+%

!elfRating b% t"e !tu#ent Counselor
Date- VVVVVVVVVVVVV "ounselor- VVVVVVVVVVVVVVVVVVVVV "lient- VVVVVVVVVVVVVVVV
Directions8 :ollowing a counseling session, please answer the following uestions(
Preparation for t"e $nter)ie& H,! L NO
1( *as 3 physically in good condition and mentally alertQ VVVV VVVV VVVV
2( *as 3 able to spend the entire session with the clientQ VVVV VVVV VVVV
&( *as pro)ision made for pri)acy and reasonable freedom from
interruptionQ VVVV VVVV VVVV
;( Did 3 ha)e the physical space arranged where we meet so as
to suggest welcome and an atmosphere conduci)e to counselingQ VVVV VVVV VVVV
.( Did 3 ha)e a background of a)ailable data about the client that
would help me understand him9her better in the inter)iew but
would not pre>udice meQ VVVV VVVV VVVV
+( Did 3 ha)e an understanding of pertinent client information so
as to personalize informational processes with the clientQ VVVV VVVV VVVV
%( *as 3 ready to see the client?s point of )iew, be genuinely
helpful, and maintain pri)acy and confidentialityQ VVVV VVVV VVVV
"omments-
9eginning t"e $nter)ie&
1( *as 3 sensiti)e to the client and did 3 use an appropriate approachQ VVVV VVVV VVVV
2( *as 3 able to create an atmosphere in which the client was
stimulated to take responsibility for their thoughts9feelings9
beha)iorsQ VVVV VVVV VVVV
&( *as 3 successful in maintaining open communication between usQ VVVV VVVV VVVV
;( *as 3 rela!ed and genuine with my )erbal and non,)erbal
communicationQ VVVV VVVV VVVV
"omments-
This material was adapted from C( Dimick and :( Crause A10<0B, 'racticum $anual for !ounseling and 'sychotherapy, @uncie, :;<
2ccelerated De)elopment 3nc(
+<
De)elopment of t"e $nter)ie& Hes L No
1( Did you create an atmosphere that allowed the client to e!press
negati)e feelingsQ VVVV VVVV VVVV
2( Did the client ha)e the opportunity to release tensionQ VVVV VVVV VVVV
&( *as my attitude one of reflecting ob>ecti)ity while e!pressing
caringQ VVVV VVVV VVVV
;( *as 3 sincere and did 3 show genuine respect for the clientQ VVVV VVVV VVVV
.( *as my own attitude, as far as 3 know, free from biasQ VVVV VVVV VVVV
+( Did 3 follow the leads Acues both )erbal and non,)erbalB
suggested by the clientQ VVVV VVVV VVVV
%( Did 3 help the client to clarify and e!pand upon positi)e feelingsQ VVVV VVVV VVVV
<( *as 3 able to assist in information processing by the clientQ VVVV VVVV VVVV
0( *as 3 able to identify areas with which to follow through for
the ne!t sessionQ VVVV VVVV VVVV
10( *as 3 able to help the client identify treatment goals and
ob>ecti)es to work onQ VVVV VVVV VVVV
11( *as the counseling session structured according to a specific
counseling theoryQ VVVV VVVV VVVV
12( Did 3 use accepted and appropriate treatment modalities
and counseling techniues based on recognized theoretical
orientations and outcome researchQ VVVV VVVV VVVV
1&( Did 3 work entirely under my scope of knowledge, training and
licenseQ KKKK KKKK KKKK
"omments-
Planning for t"e NeCt !ession
1( *as 3 able to make appropriate treatment recommendationsQ VVVV VVVV VVVV
2( Did 3 facilitate the formulation of a treatment planQ VVVV VVVV VVVV
&( Did 3 establish a treatment contract with the client and
make a concerted effort to ensure their needs, related to therapy,
ha)e been integrated into the planQ VVVV VVVV VVVV
;( Did 3 terminate the therapeutic relationship at an appropriate
timeQ VVVV VVVV VVVV
.( *as 3 sensiti)e to and knowledgeable about the impact of
multi,cultural issues and di)ersity on my client?s particular
problems and concernsQ VVVV VVVV VVVV
+( *as 3 fle!ible and knowledgeable in determining population,
appropriate counseling techniues and therapeutic inter)entionsQ VVVV VVVV VVVV
%( Fa)e 3 identified techniues that might be considered for ne!t
sessionQ VVVV VVVV VVVV
<( Fa)e 3 identified the materials and9or preparation 3 will need
for the ne!t sessionQ VVVV VVVV VVVV
"omments-
+0
Phone (513) 745-3655
Fa (513) 745-2!20
$nterns"ip at a Glance8 C"ec>list
Note: Start this rocess the semester be!ore beginning your "nternshi e#erience'
Successful completion of "#U$ %%&
3ntent :orms can be found in the back of this handbook
"omplete 3ntent :orm and return with resume attached
Schedule appointment with Dr( 7osey
@eet with Dr( 7osey and recei)e the 3nternship Fandbook
"onfirm 'lacement
8eturn 3nitial 'aperwork Asee 3nternship FandbookB
2ttend 3nternship Seminar "lass
3f you will not complete your internship by the end of the semester you must
reuest an e!tension from the "linical "oordinator
'rogress will be monitored through your attendance at regularly scheduled
on,campus meetings
Dr' 9utc" +ose%
Clinical Coor#inator
P"one8 /0132 7301@37
lose%rK.a)ier'e#u
%0
!C(OO+ COUN!,+$NG !U77,R $NT,RN!($P
Students can apply for summer internship A2pplying does not mean that the reuest will automatically
be grantedB( The decision to grant summer internship will depend on the student?s need and number of
students applying( The summer internship option is only a)ailable to students continuing their placement
from the spring semester or starting early to participate in acti)ities such as indi)idualized or group work
with students, scheduling, or staff training( Students will be reuired to register and attend classes that
are offered Eune 1.
th
through Euly 1.
th
( 3f all of the Summer 3nternship "riteria below are met, you can
apply using the application form on the ne!t page(
Summer 3nternship "riteria-
1( Lou were enrolled in the spring session #8 your site has reuested that you start early for a
specific reason(
2( Lou will not be completing all your internship hours in the summer term(
&( Lour super)isor will be at the site and a)ailable(
;( Lou will ha)e a regular schedule and will not be working from home(
%1
Application for School Counseling Summer Internship
Date Submitted_______________________________________________
Student Name________________________________________________
Site_______________________________________________________
Site Supervisor_______________________________________________
Do all of the following apply to your request?
[ ] You were enrolled in the spring session O your site has requested that you start early for a
spe!ifi! reason" #f an early start is requested$ you plan to be enrolled in the fall semester"
[ ] You will not be !ompleting all your internship hours in the summer term"
[ ] Your supervisor will be at the site and available"
[ ] You will have a regular s!hedule and will not be wor%ing from home"
eason for applying for Summer #nternship &use additional paper as needed'(
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
________________________________________
Signature Date
%2
Phone (513) 745-3655
Fa (513) 745-2!20
$ntent Form
linical !ental "ealth ounseling linical #nternship
"omplete this form at least one semester before beginning your internship( 'lease attach a resume(
$ame- VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
2ddress- VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
Daytime phone number- VVVVVVVVVVVVVVVVVVVVVVVV
"ell phone number VVVVVVVVVVVVVVVVVVVVVVVVVVVV
4mail VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
'lease list your areas of interest (for e=ample, drug.alcohol, eating disorders, college student
population, career, employee assistance, children, adolescents, adults, families&-
VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
Do you already ha)e an internship siteQ VVV yes VVV no
3f so, please state name and address of the institution-
*hat type of clinical counseling site are you seeking for your internshipQ
1( VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
2( VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
&( VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
3 would like to begin internship fall9spring9summer (please circle one& semester of 20VVV(
'lease submit this form to Dr( 6utch 7osey Aoffice located in Failstones 21&B( Lou will be contacted by
Dr( 7osey to schedule your initial appointment regarding your clinical internship(
3r. %utch 9osey
!linical !oordinator
%&
3epartment of !ounseling
%;
Phone (513) 745-3655
Fa (513) 745-2!20
$ntent Form
School ounseling #nternship
"omplete this form at least one semester before beginning your internship( 'lease attach a resume(
$ame- VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
2ddress- VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
Daytime phone number- VVVVVVVVVVVVVVVVVVVVVVVV
"ell phone number VVVVVVVVVVVVVVVVVVVVVVVVVVVV
4mail VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
Do you already ha)e an internship siteQ VVV yes VVV no
3f so, please state name and address of the institution-
*hat type of school counseling site are you seeking for your internshipQ
(check all that apply&<
VVV C,+
VVV @iddle School
VVV Figh School
3 would like to begin internship fall9spring9summer (please circle one& semester of 20VVV(
'lease submit this form to Dr( 6utch 7osey Aoffice located in 21& Failstones FallB( Lou will be
contacted by Dr( 7osey to schedule your initial appointment regarding your clinical internship(
3r. %utch 9osey
!linical !oordinator
3epartment of !ounseling
%.

Practicum Handbook Summer 2012

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Xavier University

Counseling Practicum Handbook

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